【Objective】 To evaluate the efficiency and feasibility of standardized management mode of discharged high risk neonates from NICU of primary hospital. 【Methods】 The following-up center for discharged NICU high-risk neonates was to establish and the follow-up processes and intervention model were also set up. High-risk neonates born from Jan. 2007 to Jan. 2009 were followed up with periodic evaluation, advice and guidance, and the implementation of early intervention. 【Results】 About 2 505 of high-risk neonates were recruited into this standardized management mode. The filing number and the rate of follow-up at 6month, one year and two years after this mode performed were significantly higher than that of two years before this mode performed(P<0.001). About 253 neonates with mental and motor developmental abnormalities were performed early hospital combined family intervention. Compared with control group, there was no significant difference between intellectual and motor developmental index at 2 yeas of age. 【Conclusion】 Setting up network of supervision to high-risk neonates, unified management and multi-course cooperation combined with family based intervention are efficiency and feasibility modes for primary hospital.