Background: Chronic diseases significantly burden rural healthcare systems, where continuity of care is limited.

Objective: To develop and evaluate a standardized community health nursing intervention model for improving chronic disease outcomes.

Methods: A mixed-method quasi-experimental study was conducted among 980 participants (intervention = 490; control = 490) over 6 months. The intervention included health education, home visits, self-management support, and care coordination.

Results: The intervention group showed significant reductions in systolic blood pressure (−10.0 mmHg), diastolic blood pressure (−5.5 mmHg), and fasting blood glucose (−16.3 mg/dL) (p < 0.001). Self-management and quality of life improved significantly, supported by qualitative findings on better adherence and engagement.