Objective To ensure a successful referral of disabled elderly people from hospital to family, and to construct a discharge planning service model for disabled elderly patients suitable for China′s national conditions. Methods Through literature review, semi-structured interviews, Delphi-based expert consultation and analytic hierarchy process, a discharge planning service model for disabled elderly patients and the weight of each index were determined. Results The expert authority coefficient was 0.882 for each round. The coordination coefficients of the two rounds of expert consultation were 0.123 and 0.167 respectively (P<0.01 for both). The final discharge planning service model for disabled elderly patients includes four first-level indicators(roles and functions, path to practice, core processes, and major service contents), 11 second-level indicators, and 66 third-level indicators. Conclusion The discharge planning service model for disabled elderly patients is scientific and reliable, and it can provide a basis for the research and construction of continuous nursing care model in China.