Objective To construct an "Internet + specific transitional care" model based on the intelligent follow-up module to provide home care services for older patients discharged to home. Methods Based on the intelligent follow-up system, two intelligent follow-up modules for catheter and wound/stoma were constructed based on the needs of older patients to provide home care and intelligent follow-up services. Results From January to December 2023, 632 cases of catheter care and 260 cases of wound/stoma care were provided for older patients at their home. The satisfaction score reported by 162 older patients towards this transitional care model was(5.00±0.03). Conclusion The "Internet + specific transitional care" model based on the intelligent follow-up module, can identify patients who need home care service at an early stage, and promote the continuity of care for patients discharged from hospital to home.