Insufficient income, inadequate healthcare resources, and insufficient chronic disease management awareness pose a fundamental obstacle to the sustained health maintenance of elderly individuals with chronic diseases in rural areas. In response to these challenges, this study adopted a research-through-design approach and introduced system design thinking by incorporating new stakeholders, experiential insights, and services. Initially, during the background research stage, a semi-structured interview was conducted to gain an understanding of the pains, needs, and potential opportunities of the target users. Subsequently, in the design model construction stage, desk research was carried out to refine and integrate the common components identified in various design models. In a focus group, these components were then incorporated into the development of a Sustainable Health Product-Service System Design Model tailored for rural elderly with chronic diseases after refining the pains, needs, and potential opportunities defined in the first stage. This design model encompassed elements including a background layer, a stakeholder layer, a funding layer, a product layer, a service layer, and an information layer. In the system design and design model validation stage, a design project aimed at health maintenance was launched within Liyang Town, with the design thinking method following a process of empathizing, defining, ideating, prototyping, and testing. Throughout the project, the established model guided the design process and facilitated the conceptualization and implementation of a Product-Service system. In conclusion, an investigation encompassing 15 elderly individuals was undertaken to analyze their income balance, health condition, health awareness, and their satisfaction with the health system. This analysis spanned the period both before and after their involvement in the project. The outcomes of this examination revealed notable enhancements across all three dimensions evaluated, highlighting the positive impact of the project on the elderly participants. Furthermore, the project’s social benefits were also comprehensively established.