All citizens have equal access to health services. Palliative care at home is a health service that has a tendency to increase in demand. Participation of communities and primary health care providers will lead to inclusive and sustainable delivery of services in the community. There is a tendency of people's needs for palliative care at home to increase. Because of the incidence of chronic, serious, life-threatening diseases, including the increasing proportion of the elderly, the number of terminal illness patients and the elderly at the end of life has increased accordingly. Palliative care is taking care of physical ailments, holistic mental, social and spiritual problems from the first stage of diagnosis to being in the palliative stage until the patient's death.

Many people, upon realizing their health condition, choose to return to die at home among loved ones. Therefore, there was a need for supportive care at home. This requires cooperation between specialists and health networks in the community and family members to participate in activities to help face the illness appropriately. This should result in  the best  quality of life until the last moment and the person can die peacefully with human dignity.

Khao Thong Subdistrict, Phayuha Khiri District Nakhon Sawan Province is the connection of Mahidol university Nakhonsawan campus, it is a training center for nursing students in the course of community health nursing practice. Ban Khao Thong takes care of 12 villages in the administrative area of Khao Thong subdistrict administrative organization. From the health data survey of Ban Khao Thong  health promotion hospital in 2021, it was found that there were 5,352 people actually living, 1,639 elderly people, representing 30.62 percent. of these, there were 326 people over 80 years old, accounting for 19.89 of all seniors. There are 1,614 registered patients with chronic diseases. The patients with high blood pressure, diabetes, cerebrovascular disease, chronic mental illness, chronic renal failure, and cancer, respectively, they have criteria that need  palliative care at home.

In the past, it was found that the target group of people still did not have access to comprehensive services for reasons such as the workload and the number of personnel in the primary care unit is limited. The referral system and patient information linkage between health service agencies was delayed. Additionally, community health workers and networks lack confidence in psychological care. The operator therefore uses the expertise of an Advanced Nurse Practitioner (APN) in Community Practice Nursing. I am taking the results of research and development of a continuous palliative care model at home in the primary care network applied in conjunction with the community health network of Khao Thong sub-district. Providing services in line with the problems, needs, and social contexts of the community by applying the activities with community nurse practice and public health volunteers.

Activities
1. Coordinate with staff of Ban Khao Thong Health Promoting Hospital professional nurses and related persons To clarify and understand the guideline for palliative care for terminally ill patients at home.
2. Survey the target group who are terminally ill patients in the community area.
3. Prepare a register for each patient. illness details to plan the service
4. Coordinate and clarify the form of care activities To those involved in the multidisciplinary health community leaders, village health volunteers and local administrative organizations. to perform the service and set an appointment
5. Prepare materials, equipment and care plans for each patient service.
6. Provide palliative care services for patients at home. with palliative care practices at home according to the characteristics and care needs of patients and families
7. Schedule follow-up care appointments according to the patient's needs.
8. Summary of results of the care report of patient care results for  relevant staff exchange of knowledge of caring to improve and develop to be more efficient

The results of the activities showed that there were a total of 18 participants in the intervention, divided into 10 males, 8 females, 4 terminal cancer patients, late elderly and chronic illnesses, 9 patients with chronic diseases. There were 5 cases with complications. Those who received care had PPS scores ranging from 10 to 80, with an average of 41 points. The service access rate was 75%. In evaluation of this program, patients and family members were satisfied with the services received, which could be assessed from gestures and words of gratitude to the receiving participation.