Objective To construct a continuous care model for elderly patients with chronic diseases using "Internet Plus" strategy with the aid of hospital alliance, and to evaluate the implementation effect. Methods A hospital alliance was constructed, with a tertiary hospital as the leading hospital, and a secondary hospital, a community hospital, 14 community health service centers and 43 village clinics. Elderly patients with chronic diseases discharged from these medical institutions received continuous care with the assistance of Internet technology. Patient satisfaction, caregiver burden, and professional identity of nurses were evaluated before and after the intervention. Results After 2 years and 7 months of implementation, the total number of service provision was 1,859, with the most service being gastric tube care (37.32%), followed by urethral catheterization and related care (35.87%). Patient satisfaction with 9 items ranged from 75.59% to 100%. Caregiver burden was significantly decreased, while nurses′ professional identity was significantly enhanced after the intervention (both P<0.05). Conclusion Implementation of continuous care for elderly patients with chronic diseases using "Internet Plus" strategy with the aid of hospital alliance meets the needs of elderly patients, improve their satisfaction, reduce burden of family caregivers, and also enhance professional identity of nurses.