A real employment or credential role may perform many tasks across the SOPs. A task name, procedure occurrence, participation basis, or software function never creates another role. The selected step links the task back to the same canonical role and states its entry trigger. The directory contains 13 internal human categories in total: ten routine service/support categories and three rare clinical or legal escalation authorities. Procedure steps and trace rows are coverage evidence, not additional roles. For example, assessment review and medication review are different tasks under the same U.S. clinician category when the named clinician's license, scope, beneficiary location, and assignment permit both acts.
Eight-pillar episode systemAssessment → Care Plan → distinct service work → Ongoing return7 procedure steps
Procedure touchpointEstablish an attributable baseline
Reviews the accessible assessment questions, supplies or corrects lived facts, goals, and priorities, and identifies any item declined or still unknown for the attributable baseline.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointConvert accepted choices into owned actions
Chooses the goals, options, refusals, and plan content that will be carried forward.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointOffer the configured Proxi companion interaction
Responds to the permission-scoped interaction, supplies or corrects an attributable self-report, accepts or declines offered action help, and states whether a person is requested.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointReturn the result and the next useful action
Reports lived outcome, value, barriers, preferences, and changed needs.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointEnter laterally through 24/7
States the immediate need directly when the beneficiary is the caller.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Reports current instructions, possession, use, symptoms, understanding, and uncertainty.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointRespond to caregiver exhaustion or possible breakdown
Participates in affected beneficiary safeguards and plan choices without absorbing the caregiver's concern as a diagnosis.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Eight-pillar episode systemHandoff and truthful-completion ladder2 procedure steps
Procedure touchpointName one exact receiving obligation
Supplies the choice or request when the receiving obligation depends on beneficiary direction.
Procedure touchpointProduce and return the local SOP result
Receives the result and reports lived outcome or remaining need.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Eight-pillar episode systemSame-interaction service attribution and count-once labor1 procedure step
Procedure touchpointAvoid a redundant person-facing contact
Chooses preferred timing and receives a contact only for applicable person-specific value.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Eight-pillar episode systemWorked episode: “My mother will not bathe”1 procedure step
Procedure touchpointAnswer and capture the immediate need
States the need directly when the beneficiary is calling.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointCapture the exact conflict and current situation
Reports the discharge instruction, current medication/use, symptoms, location, and uncertainty.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointMake the scoped reconciliation decision
Receives the current instruction and supplies direct understanding/use information.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointTrack execution, understanding, use, and return separately
Reports receipt, understanding, actual use, effects, barriers, and new questions.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Eight-pillar episode systemWorked episode: caregiver exhaustion or possible breakdown1 procedure step
Procedure touchpointUpdate only affected contingencies and safeguards
Directs affected beneficiary plan choices and participates in permissible safeguard planning.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Eight-pillar episode systemDaily Companion and caregiver pulse5 procedure steps
Procedure touchpointVerify identity and current permission
Authenticates and supplies current participation or permission choices.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointShow the last confirmed picture
Views their permitted last-confirmed information and open actions.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointOffer the beneficiary interaction
Chooses to participate, defer, decline, change channel, or request a person.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointComplete the routed work and return a disposition
Corrects the prepared summary and participates in the actual service when applicable.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointReturn one useful action plan
Receives the accessible recap, current owners, unknowns, and next result.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointConfirm people, access, modality, schedule, and packet
Confirms identity, caregiver participation, communication needs, modality, and preferred schedule.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointWork history, cognition, function, hearing, staging, and medication
Supplies direct history, cognition/function experience, medication use, symptoms, and current concerns.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointScreen behavioral health, safety, environment, and social needs
Answers approved behavioral, safety, environment, and social-needs questions and states preferences or refusals.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointCapture advance wishes, providers, services, and coordination need
States advance-care-planning wishes and confirms current providers, services, priorities, and requested coordination.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointAssess caregiver capacity—or use the no-caregiver branch
States caregiver involvement preferences and participates in beneficiary safeguard planning.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointDetermine and complete the residence work
Participates in the residence visit and supplies direct home-context preferences and facts.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointSynthesize, discuss, hand off, and document completion
Receives and corrects the person-facing result, states priorities, and participates in next-step choices.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Comprehensive Assessment procedure mapAssessment finding: continue, pause a dependency, or route immediately1 procedure step
Procedure touchpointPreserve the exact response and source
Supplies the exact response, refusal, uncertainty, or inability to answer.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Person-Centered Care Plan procedure mapFrom current facts and beneficiary direction to owned action6 procedure steps
Procedure touchpointOpen the work and establish participation
Directs participation, caregiver involvement, goals, communication needs, and the planning conversation.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointElicit what matters, goals, strengths, preferences, and concerns
States what matters, goals, strengths, preferences, unmet needs, concerns, choices, and refusals in the beneficiary's own terms.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointPrepare options and obtain actual decisions
Chooses or refuses plan content after options and tradeoffs are presented.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointReview and revise; hold finalization until authority is settled
Reviews the draft, directs revisions, confirms refusals, and decides accepted plan content.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointRecord and distribute the current plan
Receives the current plan and supporting resources through a usable approved channel.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointSend actions, confirm custody, follow results, and revise
Performs beneficiary-owned actions and reports what happened, whether it helped, and what remains.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Person-Centered Care Plan procedure mapAccepted action to real result and affected-plan return3 procedure steps
Procedure touchpointConfirm receipt and custody
Accepts a beneficiary-owned action and states whether able/willing to proceed.
Procedure touchpointFollow the goal and actual service result
Reports performance, lived outcome, value, barriers, changed goals/preferences, and requested next help.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointRevise only when needed or requested
Requests or confirms the change and directs the affected plan content.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Ongoing Monitoring and Support procedure mapFrom relationship and cadence to a useful return4 procedure steps
Procedure touchpointEstablish the relationship and applicable cadence
Chooses who participates, usable modalities, accommodations, and availability.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointPrepare and conduct a qualifying, person-specific contact
Participates directly, reports what matters or changed, and directs preference-sensitive next steps.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointAct only on the applicable unmet need or concern
Reports the need or barrier and chooses among optional services or supports.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointAgree, document, count, recover, and complete promised work
Confirms the practical next action and later reports whether it helped.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Ongoing Monitoring and Support procedure mapUseful contact and material-change branch4 procedure steps
Procedure touchpointPrepare recent promises, results, and known open work
Supplies prior reported concerns, preferences, and outcomes that remain visibly attributed.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointAsk what changed or matters now
Reports what changed, what matters, and what help is wanted.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointCheck plan fit only when the conversation makes it relevant
States whether the relevant goal, preference, support, responsibility, or action still fits and directs person-centered changes.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointAgree on the next useful action
Confirms the understandable next action and how the result should return.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
24/7 Access procedure mapFrom continuously available human access to truthful follow-through5 procedure steps
Procedure touchpointMaintain a usable, continuously human-covered route
Receives the number and instructions and confirms that the route is usable.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointAnswer, recover, and capture the need without clinical triage
Calls directly, reports the concern, and receives dementia-capable human communication.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointUse the correct live help route
Supplies the source report and receives the human or emergency route.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointRecord, share, confirm custody, call back, and carry forward
Receives the promised callback, understands the next action, and reports whether the immediate concern remains.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointRecover outages and learn from repeated calls
Receives the restored route and directs any person-centered change arising from repeated needs.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointAnswer—or actively recover a disconnected call
Uses the route directly and provides a callback route when available.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointEstablish caller, beneficiary, current need, and usable callback
Identifies self and reports the current need when the beneficiary is the caller.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointInvoke the approved emergency route
Supplies the source report and receives the emergency or urgent route.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointAnswer a permitted navigation or program question
Asks the question and confirms whether the answer or next route is understood.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointConnect a clinical issue directly
Supplies the source report and receives the clinician's direction.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointFurnish or hand off the applicable GUIDE support
May request the caregiver support call or be the beneficiary whose care creates the support need.
Care Coordination and Transitional Care procedure mapChoose the exact coordination route and close on a returned result4 procedure steps
Procedure touchpointCoordinate with an outside PCP
Confirms the current PCP, participation preferences, and person-centered choices arising from returned information.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointRun the specialist referral and return loop
Chooses the provider and whether to proceed, supplies access preferences, and participates in resulting care choices.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointCoordinate a care-setting transition
Reports what occurred and is understood, identifies current needs, and directs person-centered choices.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointWork another exact clinical coordination dependency
States the desired outcome and participates in any resulting person-centered choice.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Care Coordination and Transitional Care procedure mapSpecialist referral: clinical need to returned recommendation4 procedure steps
Procedure touchpointDefine the clinical need and purpose
Supplies relevant goals, reported symptoms, prior experience, and preference to proceed; not the clinical determination.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointPrepare factual options and support beneficiary choice
Chooses whether to proceed and selects the provider from current factual options.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointRelease the referral and arrange the visit
Confirms the chosen provider, availability, appointment, and whether optional help or introduction is wanted.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointReview, explain, and carry forward the result
Receives the understandable result and participates in accepted care-plan and next-work choices.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Care Coordination and Transitional Care procedure mapCare-setting transition return loop4 procedure steps
Procedure touchpointDetect and confirm the current situation
Reports or confirms the transition, current setting, location, and known situation.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointContact the person and recover transition records
Reports the transition experience, understanding, immediate barriers, and desired help.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointOpen distinct affected work in parallel
Chooses optional services and receives the distinct clinical, medication, referral, and follow-up routes.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointReinforce approved instructions and return reviewed results
Receives approved instructions and reviewed results, demonstrates understanding, and directs person-centered plan choices.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Referral and Services Supports procedure mapFrom a current need to a real-world service result3 procedure steps
Procedure touchpointComplete the individual community-connection loop
States the beneficiary's need and constraints, chooses an option, permits participation, and reports the real-world result.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointMaintain a usable service inventory
Receives only relevant current options, source limitations, and a truthful no-match result.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointCoordinate GUIDE with Medicaid HCBS
Confirms participation preference, reports current HCBS experience, and chooses how to address identified gaps.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Referral and Services Supports procedure mapIndividual referral: need to actual service result5 procedure steps
Procedure touchpointDefine the need and desired result
States the beneficiary's current need, desired result, constraints, and preferences.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointSearch, verify, and present current factual options
Reviews current factual options, uncertainties, and tradeoffs before choosing.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointChoose the option and authorize the appropriate sharing
Chooses the option and supplies the beneficiary's participation and outreach preference.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointSend, confirm receipt, and help complete intake
Supplies required person facts and participates in intake steps that only the service seeker can complete.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointConfirm start and whether the service meets the need
Reports whether the service started and whether it meets the beneficiary's stated need.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Medication Management and Reconciliation procedure mapFrom a real trigger to an authorized regimen result and real-world use7 procedure steps
Procedure touchpointConfirm the trigger and assemble every relevant source
Reports actual medication use, symptoms, barriers, transitions, and current questions.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointMatch, compare, pursue missing facts, and prepare the review
Confirms, corrects, or leaves unknown the person's actual-use report and practical barriers.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointPerform reconciliation and author the medication result
Provides clinically necessary history and receives the authorized regimen explanation and next action.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointWhen changing medication, separate proposal, agreement, choice, and order
Makes the beneficiary's informed choice after receiving the authorized explanation.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointTrack order, pharmacy, possession, instruction, use, and monitoring separately
Reports possession, actual use, refusal, self-change, barriers, symptoms, and the ability to follow the authorized instruction.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointProvide schedule and access support without choosing treatment
Chooses the usable schedule or access support and reports whether it works.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointUse the medication-safety bypass
Supplies the person's exact symptom, medication, safety, location, and callback report when able.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Medication Management and Reconciliation procedure mapMedication source packet to clinician-authored reconciliation result5 procedure steps
Procedure touchpointMatch exact products and preserve ambiguity
Supplies a label, container, photograph, or reported product name as person-reported evidence.
Enters when: When person-supplied evidence is needed to identify what is possessed or reportedly used.Open exact procedure step →
Procedure touchpointCompare all source assertions literally
Confirms or corrects the person's actual-use report.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Provides any clinically necessary history and receives the authorized result.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointRecord complete-no-change, complete-with-change, or incomplete
Receives the accessible result, safeguards, and next action.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointExplain the reconciled result and remaining uncertainty
Receives the explanation, asks questions, and confirms or corrects understanding and intended next action.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Medication Management and Reconciliation procedure mapOrder-to-use evidence ladder3 procedure steps
Procedure touchpointResolve the pharmacy execution state
Reports handoff, non-handoff, possession, cost, access, or refusal without converting the report into a pharmacy event.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointSynchronize destinations and give exact final instructions
Receives the exact instruction and confirms questions, understanding, and intended next action.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointConfirm implementation and complete defined monitoring
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Caregiver Education and Support procedure mapFrom caregiver applicability to a human-owned useful result3 procedure steps
Procedure touchpointConfirm applicability—or use the no-caregiver branch
Identifies possible caregivers, states participation preferences, and supplies or limits outreach permission.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointReview assessment, priorities, plan, and available services
Supplies separate beneficiary preferences or facts relevant to the caregiver-support plan.
Enters when: When relevant and permitted; beneficiary and caregiver facts remain separately attributed.Open exact procedure step →
Procedure touchpointReassess caregiver need and update support
Supplies separately attributed beneficiary information affected by the caregiver change.
Enters when: When a caregiver change affects beneficiary participation or service work.Open exact procedure step →
Caregiver Education and Support procedure mapNo-caregiver branch: stop caregiver services, continue beneficiary safeguards2 procedure steps
Procedure touchpointMake a reasonable effort to identify a caregiver
Identifies possible unpaid helpers, states relevant preferences, and permits or declines outreach.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
Procedure touchpointOpen and follow the added beneficiary safeguards
States needs and preferences, participates directly, and chooses permissible nonclinical supports.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
People and accountable organizations
Canonical actor roster
Each selected diagram step shows the exact task and entry condition under the same canonical role; the linked SOP carries the full procedure.
People who furnish or support GUIDE services
L1
Philippine 24/7 and coordination support
Proxi's Philippines-based human first-answer and administrative support team.
$5.50/hour planning assumption · July 14, 2026
Functions this category may perform
24/7 human first answer, identity and callback capture, and warm transfer
Scheduling, record pursuit, endpoint verification, structured intake, and failed-route recovery
Source-faithful documentation and permitted administrative follow-through
Authority
Performs approved nonclinical first-answer and administrative acts.
Hard boundary
Not a GUIDE navigator contact and never clinical triage, medication reconciliation, treatment, or U.S.-licensed work. A Philippine RN credential does not expand this lane.
82 linked procedure steps across 26 procedure maps
Each step lists the exact task performed by this same job role. The steps are not additional roles or capacities.
Puerto Rico-based nonclinical dementia care navigator with current Alzheimer’s Association® essentiALZ® certification for dementia care navigation.
$22/hour all-inclusive planning assumption · July 14, 2026
Functions this category may perform
Primary relationship, required GUIDE contact, and beneficiary-led care-plan facilitation
Nonclinical assessment contribution, caregiver support, community coordination, and warm introductions
Caregiver-training tasks only when the named navigator's verified competency covers the subject
Human clarification for ambiguity, disagreement, distress, accessibility failure, or requested relationship help
Authority
Performs the specifically required or valuable nonclinical human GUIDE task after preparation. A training task requires verified subject-specific competency; it does not create a separate trainer job category.
Hard boundary
No clinical or medical work, even if an individual also holds an RN or other professional credential. A topic outside the navigator's verified training competency routes to the applicable U.S. clinician or an approved outside training provider. Not the default fact collector, option builder, or gateway to a clinician.
113 linked procedure steps across 26 procedure maps
Each step lists the exact task performed by this same job role. The steps are not additional roles or capacities.
A dementia-proficient NP, PA, CNS, physician, or other exact prescribing/E/M professional authorized for the beneficiary location and act.
$140/hour planning assumption · July 14, 2026
Functions this category may perform
Required examination and clinically necessary history
Diagnosis, staging, treatment, medication reconciliation, prescribing, and medical orders
Higher-authority clinical contribution to assessment, care planning, transitions, and follow-up
Authority
Exercises only the medical and prescribing authority actually held by the named professional.
Hard boundary
Receives a prepared source-linked packet; routine record hunting, form population, scheduling, and administrative chasing occur before this role enters.
89 linked procedure steps across 25 procedure maps
Each step lists the exact task performed by this same job role. The steps are not additional roles or capacities.
The administrative subject-matter professional for state Medicaid benefits, waivers, coverage authorities, eligibility interfaces, and Medicaid responsibility questions.
Concrete work
Resolve a bounded Medicaid program or coverage-authority question
Identify the authoritative state, plan, waiver, payer, or agency source
Separate Medicaid responsibility from GUIDE and claim-processing work
Authority
Interprets the approved Medicaid program materials within assigned administrative scope.
Hard boundary
Not a clinician, navigator, eligibility adjudicator beyond delegated authority, or second revenue-cycle queue.
No routine procedure task
This job enters through a concrete failure or escalation route, not as a standing reviewer.
These leaders enter only for the issue inside their actual authority. They do not bless routine work.
Escalation authority
Head of nursing and clinical operations
The U.S. nursing leader accountable for nursing-practice quality, RN clinical operations, and escalations beyond the original nurse or first-line clinical supervisor.
Concrete work
Review a serious or repeated RN-practice issue
Set and correct nursing-practice and clinical-operations standards
Assign the responsible nursing correction and verify recovery
Authority
Exercises nursing leadership within actual organizational, licensure, and jurisdictional authority.
Hard boundary
Not a reviewer for administrative, navigator, billing, privacy, software, or physician-quality work.
1 linked procedure step across 1 procedure map
Each step lists the exact task performed by this same job role. The steps are not additional roles or capacities.
The physician executive used for physician/medical quality, high-level medical judgment review, and medical-staff accountability when the issue exceeds the original clinician.
Concrete work
Review a serious physician or medical-quality issue
Resolve high-level medical-practice escalation within actual authority
Assign the responsible medical correction and verify its disposition
Authority
Exercises physician medical leadership within the CMO's actual organizational and professional authority.
Hard boundary
Not a rubber stamp for routine care plans, RN work, missed callbacks, staffing gaps, or administrative failures.
No routine procedure task
This job enters through a concrete failure or escalation route, not as a standing reviewer.
The named person or body inside the GUIDE Participant that retains a nondelegable approval, signature, attestation, or organizational accountability act.
Functions
Participant-retained approval, attestation, signature, or final accountability
Assignment and oversight required by the Participation Agreement or approved policy
Reviewer-visible subtype or participation basis
Exact retained Participant body
Exact retained approval, release, signature, attestation, or accountability act
Authority
Performs only the exact act that cannot be delegated or that the Participant has expressly retained.
Boundary
Not automatically the navigator or clinician and not a universal approver. Exact unresolved authority remains an open decision rather than a placeholder role.
No routine procedure task
This job enters through a concrete failure or escalation route, not as a standing reviewer.
The typed outside endpoint that controls an external act: PCP, specialist, pharmacy, hospital/facility, emergency service, payer, community organization, Medicaid/AAA/Tribal Aging Program, or contracted field professional.
Functions
Co-management, concurrence, direct treatment, dispense, coverage/intake decision, emergency response, or real-world service delivery
Returns source-native evidence of the outside result or truthful non-success
Reviewer-visible subtype or participation basis
PCP or primary care practice
Specialist, prescribing clinician, diagnostic provider, or laboratory
Pharmacy, supplier, hospital, facility, home-health, or hospice organization
Emergency, crisis, poison-control, or protective-service responder
Payer, Medicaid HCBS program, AAA, or Tribal Aging Program
Community service, caregiver support, training, transportation, interpreter, accessibility, or communications provider
Authority
Controls only the external decision or performance within that party's real role.
Boundary
Proxi may prepare, connect, pursue, and report; it cannot manufacture the external result from a send, appointment, claim, or acknowledgement. An external system is channel metadata for the typed endpoint, not a person or a Proxi software surface.
89 linked procedure steps across 26 procedure maps
These are participation or outside-party touchpoints. They are not Proxi employment roles.
Each linked task opens its definition, permitted job categories, and controlling procedure instead of creating a phantom role.
Task-routing rule
Assessment team or owner
The people accountable for the particular assessment act, not one standing job title.
How the exact person is selected
Resolve each task to the Puerto Rico navigator, exact U.S. RN, behavioral clinician, medical clinician, beneficiary/caregiver, or outside source shown in that assessment step.
The canonical person assigned the particular Care Plan action or protected contribution.
How the exact person is selected
The beneficiary leads choices; the navigator facilitates and owns nonclinical follow-through; an exact U.S. clinician owns protected clinical judgment; outside or Participant acts stay with those parties.
The canonical performer of the applicable caregiver education, support, training, or protected clinical contribution.
How the exact person is selected
Relationship and application work resolves to the Puerto Rico navigator. A training task may be assigned to a navigator only when that named navigator's verified competency covers the subject; protected clinical content resolves to the exact U.S. clinician, and approved contracted training may resolve to an outside provider.
A function requiring actual prescribing authority for the beneficiary location and act.
How the exact person is selected
It resolves to Proxi's exact U.S. L4 clinician only when Proxi supplies that clinician; otherwise it resolves to the typed outside prescribing clinician.
Repeated failure — supervisory task in the same job lane
An approved senior Philippine L1 worker or Puerto Rico GUIDE navigator performs the specific reassignment or recovery task after the owning SOP's repeat-failure trigger. This is a task and seniority assignment inside the same job category, not a new role. Nursing-quality or physician-quality questions enter the separate Head of nursing or CMO authority only when their protected judgment is actually required.
Nursing quality goes to the Head of nursing, physician or medical quality to the CMO, and a genuine uncovered legal question to healthcare counsel. The affected act remains held.
Run the approved software rule and keep the original worker responsible for ordinary completion or correction.
If human recovery is needed, use that worker's named lane lead before creating work for another department.
Classify the remaining issue by the observable work: system operation, software defect, claim, Medicaid, workforce, nursing quality, medical quality, or legal interpretation.
Assign one named rostered person from the matching real job category and state the exact input, act, output, due time, and return recipient.
Keep portfolio work outside the beneficiary episode. HR roster repair, system incidents, and QA sampling do not become furnished GUIDE services.
If no real role has the required authority, hold only the affected act and resolve the policy or organizational gap before field use.
Routine work correction
Canonical job category
The original worker; then that worker's Philippine, Puerto Rico, or clinical lane lead
Person enters when
A handoff, callback, service record, or assigned action remains incomplete after the approved automated retry
Work
Correct the original work inside the same lane; the lead enters only after the defined repeat-failure or dispute threshold.
Output
Corrected work, named next action, due time, and recovery evidence.
Episode boundary
Beneficiary episode. Quality is a responsibility of the applicable lane lead, not a separate case specialist.
A state Medicaid benefit, waiver, coverage authority, eligibility interface, or Medicaid responsibility question cannot be resolved from the approved rule and verified facts
Work
Resolve the bounded Medicaid program question or identify the authoritative outside source needed.
Output
Cited Medicaid disposition, missing source, or external referral; no GUIDE clinical decision.
Episode boundary
Program expertise. This is not a second billing queue.
Return rule: the enabling or escalation role returns its result to the service worker responsible for the affected action. It does not take over the beneficiary relationship.
Preparation and orchestration are visible, but they never borrow human authority.
01
Proxi Daily Companion
Configurable daily beneficiary interaction, approved information, reminders, action help, source-attributed self-report, and a direct request for a person.
Boundary
Not a qualifying navigator contact, 24/7 human first answer, clinical monitor, diagnosis, urgency decision, or service-completion event. Silence stays unknown.
02
Caregiver Companion View
Permission-scoped, source-dated last-confirmed beneficiary information, open actions, explicit unknowns, a fresh-check request, and an optional caregiver pulse.
Boundary
Does not expose unauthorized information, convert caregiver observation into beneficiary fact, score distress, or present synthetic clinical status. Silence, stale data, and conflict remain unknown and never become reassurance.
03
Staff Preparation and AI Workspace
Retrieval, source links, contradictions, unknowns, prior promises, approved explanations, options, summaries, and the exact unresolved question.
Boundary
Prepares and advises within approved content; it does not resolve the question, choose for the person, or prove human review.
04
Deterministic Routing and Takeover
Approved routing, no-repeat context transfer, retries, failed-handoff recovery, and preservation of the original issue.
Boundary
AI cannot select clinical urgency, authority, disclosure, service credit, or closure.
05
Action and Result Tracker
Promises, owners, deadlines, external responses, receiving acceptance, due work, returned results, corrections, and affected-pillar feeds.
Boundary
A send, alert, appointment, handoff, named owner, or dashboard state is not completion.
Proxi product layer · not a ninth pillar
Daily companion and caregiver pulse
Daily availability feeds the right service; it does not manufacture one.
Verify identity and permission.Use the person's current scope, not family relationship or old access.
Show the last confirmed picture.Every material item carries its source and as-of time; unknown stays unknown.
Offer a beneficiary interaction.The beneficiary may participate, defer, decline, or ask for a person.
Ask the optional caregiver pulse.Capture how the caregiver is holding up and whether help is wanted as caregiver-owned information.
Prepare; do not decide.Proxi retrieves context, preserves exact reports, and raises configured stop candidates.
Route to the real performer.L1, L2, the exact L3/L4 professional, a concrete enabling department or escalation authority, or the outside endpoint completes the named work and returns a disposition or source-native evidence.
Return one action plan.State what happened, which canonical actor is assigned each action, what remains unknown, and when the result is expected.
No response is not stability. Companion activity alone is not a human GUIDE contact, 24/7 human answer, caregiver assessment or support call, clinical assessment, or service credit.
Mechanical reviewer check
If a name does not resolve here, it is a phantom actor.
A diagram links concrete work and an entry condition to a canonical person. It may state a credential or seniority condition on the task, participation basis, or outside-party type. It may not create a new role from a task, combine software and a human into one label, or put a ledger, packet, calendar, route, or work queue in the actor lane.
A linked task phrase in a source manual returns here when the exact performer depends on the episode or an open authority decision. The selected diagram step must resolve that task to the applicable canonical actor and state the work performed; the task link itself never claims a new person.