为满足国内农村失能老人不断增长的长期照护需求，适应大数据时代远程照护发展趋势，基于前期课题组实施“脑卒中失能患者连续康复护理模式”的初步效果，针对目前国内农村失能老人的照护供需矛盾突出、参与和保障不足现状，本研究拟以远程医学理论及技术为指导,基于广泛的调查研究和大量的实践数据,提出“农村失能老人医养一体化远程照护模式”,分析论证该模式运行的贡献因子及表达指标；按照信息化、专业化、整体化原则,结合主、客观法确立远程照护模式实践路径；整合不同照护主体的资源优势,对模式进行实证研究，验证其现实推广性及指标信效度；基于复杂科学理论、生态位理论揭示远程照护各主体对积极老龄化的作用机制，并结合路径分析凝练该模式的发展策略。从机制和实践评价角度解决农村失能老人长期照护的瓶颈问题，为远程照护的规范化、系统化管理提供实践基础，为相关卫生政策提供技术、实践层面的支撑性建议和理论依据。

In order to meet the rural disabled elderly’s increasing need for long-term care, adapt to development trend of telenursing discipline in the age of big data, it is based on the former research results of the “stroke continuous rehabilitation nursing model”, in view of the current status that domestic rural disabled elderly care has sever contradiction between supply and requirement, participation and security are insufficient, this study intends to build a medical-nursing integration telenursing model of the rural disabled elderly, under the guidelines of telemedicine theory and technology, based on extensive investigations and large amount of practical data , besides that, analyze and demonstrate contribution factor and indicators which influences the model’s operation. According to the informationalized, specialized and holistic principle, we plan to establish telenursing model practice path by combining subjective method with objective method. This research will also integrate the advantages of the resources provided by different caregivers, build telenursing model to do empirical study, verify the model’s practical significance of further popularization, the reliability and validity of the variables, reveal different telenursing caregivers’mechanism of action on active aging based on complex science theory and niche theory, build and compact this model’s development strategy combaining path analysis. We aims to solve the bottleneck problem on long-term care for rural disabled elderly from the perspective of mechanism and practical evaluation, laying a practical foundation for standardized , systematic management of telecare, providing supportive advice and theoretical foundation for relevant health policy in the level of technology and practice.