Objective: This study aimed to explore the impact of a comprehensive intervention system, integrating structured education, stepwise pulmonary rehabilitation, digital monitoring, and multidisciplinary follow-up within a “hospital-community-family” tri-level framework, on the prognosis of COPD patients. Methods: A prospective randomized controlled trial was conducted with 200 COPD patients diagnosed through grassroots screening in Hongze District from January to December 2021. Participants were randomly assigned to an observation group (comprehensive intervention) or a control group (routine treatment) for a 12-month follow-up. Outcomes, including pulmonary function indices (FEV₁, FVC, FEV₁/FVC), mMRC dyspnea scores, 6-minute walking distance (6MWD), and 1-year readmission rates, were compared. Results: The observation group demonstrated a 97% improvement in FEV₁ (vs. 45% in controls), a 57.7% reduction in mMRC scores (vs. 29.2%), a 51.5% increase in 6MWD (vs. 19.0%), and a 47.4% lower readmission rate (p = 0.049). Conclusion: The closed-loop management mechanism of education-rehabilitation-monitoring significantly improved pulmonary function, exercise tolerance, and dyspnea severity while reducing readmission risks in COPD patients. The intervention exhibited cumulative efficacy over time, highlighting its critical clinical application value for community-based COPD management.