This guide outlines hospital-to-home transition guidelines to ensure a successful transition of an at-risk infant. Interagency planning is discussed, with the benefits for families, hospitals, and infant-toddler service providers highlighted. Steps that transition planners should follow to ensure a sound transition plan are provided. Useful suggestions are made by hospital-community transition planning teams. Information is provided on the following topics: identifying and monitoring potentially eligible children; referring eligible children to the community; facilitating the transition from hospital to home; supporting the family role in transition; formulating a family transition plan; initiating the referral to community programs; and providing community feedback to the referring hospital. Screening and evaluation issues are also discussed. An infant at-risk criteria checklist and an infant at-risk referral/discharge notification form are attached. Contains references for families, planners, and physicians. (CR)