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 return8 procedure steps
SOP taskEstablish an attributable baseline
Reviews the prepared nonclinical gaps, conducts the assigned relationship, caregiver, home, and social assessment work, documents source-attributed findings and unknowns, and explains the resulting next actions.
Enters when: Only for assigned nonclinical assessment domains or when the person requests or requires a human relationship, clarification, or accessibility route.Open exact procedure step →
SOP taskConvert accepted choices into owned actions
Performs the required or requested human planning relationship and resolves nonclinical ambiguity without choosing for the beneficiary.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskOffer the configured Proxi companion interaction
Reviews the prepared nonclinical report and unresolved question, provides the requested GUIDE relationship or caregiver-support act, agrees the next action with the person, and documents the result and next assigned canonical actor.
Enters when: Only when an L2 human act is required by the service or requested by the person; Companion activity alone does not create it.Open exact procedure step →
SOP taskFurnish the distinct service
Reviews the prepared nonclinical obligation, provides the assigned GUIDE navigation, caregiver, education, or relationship service, confirms the person's choice or understanding, and documents the result and next assigned canonical actor.
Enters when: Only when the distinct obligation requires or the person requests an L2 nonclinical GUIDE relationship, navigation, education, or caregiver-support act.Open exact procedure step →
SOP taskReturn the result and the next useful action
Conducts the required relationship-based contact, follows promises and results, and opens only useful affected work.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskEnter laterally through 24/7
Provides bounded caregiver support or receives relationship-based follow-on work.
Coordinates logistics, obtains relationship context, and supports practical understanding and use without reconciling medication.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskRespond to caregiver exhaustion or possible breakdown
Provides substantive nonclinical support, education, contingency planning, and relationship-based follow-through.
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 ladder4 procedure steps
SOP taskPrepare the no-repeat packet
Adds beneficiary/caregiver preference, permission, or practical context without re-gathering the packet.
SOP taskRepair failure without dropping the obligation
Repairs beneficiary/caregiver refusal, misunderstanding, or relationship-sensitive ownership without deciding protected questions.
Reassigns navigator work or resolves a navigator-service ownership dispute after the original navigator cannot complete the approved recovery.
Enters when: Only when that human work is needed.; Only after the owning handoff rule reaches its navigator reassignment or supervision threshold, and only for a Puerto Rico GUIDE navigator with the approved seniority assignment for this recovery task.Open exact procedure step →
Eight-pillar episode systemSame-interaction service attribution and count-once labor3 procedure steps
SOP taskRecord the interaction and each human act once
Bundles useful relationship work and avoids repeating same-interaction services.
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”2 procedure steps
SOP taskFurnish bounded same-call support when permitted
Reinforces approved nonclinical guidance and obtains one practical next action without presenting a full course as 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 →
SOP taskOpen only the needed follow-on services
Receives full caregiver education, navigation, plan, referral, assessment, or ongoing work within L2 scope.
Supplies beneficiary/caregiver transition context and handles relationship-dependent logistics without interpreting the medication conflict.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskTrack execution, understanding, use, and return separately
Supports understanding, access, routine use, and ongoing follow-through without changing the clinical 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 →
Eight-pillar episode systemWorked episode: caregiver exhaustion or possible breakdown4 procedure steps
SOP taskPreserve the caregiver's exact words and ownership
Receives the caregiver-owned concern for nonclinical support and relationship work.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskRoute protected or immediate concerns directly
Connects the protected route and continues separately permitted support without clinically triaging.
SOP taskFurnish support and let the caregiver choose next help
Furnishes substantive one-to-one nonclinical support and presents prepared education, group, counseling, or resource 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 →
SOP taskUpdate only affected contingencies and safeguards
Updates affected nonclinical contingencies, plan actions, Assessment domains, and Ongoing follow-through with the beneficiary.
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 pulse2 procedure steps
SOP taskRoute to the real performer
Receives required/requested nonclinical GUIDE relationship or caregiver work.
SOP taskComplete the routed work and return a disposition
Reviews the prepared nonclinical question, performs the requested GUIDE relationship, navigation, education, or caregiver-support act, confirms the person's next action, and documents the result.
SOP taskConfirm people, access, modality, schedule, and packet
Confirms caregiver participation, communication/accessibility, and relationship-sensitive setup when human work is required.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskWork history, cognition, function, hearing, staging, and medication
Performs assigned nonclinical ADL/IADL and relationship-supported fact collection without clinical interpretation.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskScreen behavioral health, safety, environment, and social needs
Performs assigned environment, wandering, home, social-needs, and nonclinical support work without clinical triage.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskCapture advance wishes, providers, services, and coordination need
Facilitates advance wishes, identifies current providers/services, and opens exact nonclinical coordination 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 →
SOP taskAssess caregiver capacity—or use the no-caregiver branch
Performs assigned nonclinical caregiver assessment, support discussion, and no-caregiver 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 →
SOP taskDetermine and complete the residence work
Determines the applicable nonclinical visit logistics and conducts assigned residence safety, navigation, function, and context work.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskSynthesize, discuss, hand off, and document completion
Explains nonclinical findings and next steps, confirms beneficiary/caregiver understanding and direction, and delivers the baseline to 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 →
Comprehensive Assessment procedure mapAssessment finding: continue, pause a dependency, or route immediately3 procedure steps
SOP taskPreserve the exact response and source
Captures exact nonclinical responses and limitations without clinical inference.
Person-Centered Care Plan procedure mapFrom current facts and beneficiary direction to owned action8 procedure steps
SOP taskOpen the work and establish participation
Establishes the required or requested planning relationship, supports communication, and preserves beneficiary leadership.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskAssemble the current source packet
Reviews the prepared packet for the human planning work; does not repeat routine collection.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskElicit what matters, goals, strengths, preferences, and concerns
Performs the relationship-based conversation, supports comprehension, and clarifies nonclinical ambiguity without choosing or forcing agreement.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskPrepare options and obtain actual decisions
Explains prepared nonclinical options, resolves practical ambiguity, and supports relationship-dependent choices without blessing clear authenticated 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 →
SOP taskDraft, content-check, and make the plan accessible
Corrects relationship, accessibility, beneficiary-direction, or nonclinical meaning that cannot be resolved through direct review.
SOP taskReview and revise; hold finalization until authority is settled
Facilitates final human review, confirms nonclinical corrections and beneficiary direction, and prepares the plan for the still-open completion authority.
Enters when: Does not sign or finalize unless O-003 later assigns that exact act within scope.Open exact procedure step →
SOP taskRecord and distribute the current plan
Resolves beneficiary/caregiver recipient ambiguity or provides needed explanation without authorizing release.
SOP taskSend actions, confirm custody, follow results, and revise
Supports relationship-sensitive handoffs, conducts ongoing follow-up, and returns person-reported results for affected-plan review.
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 return4 procedure steps
SOP taskSend the accepted action for execution
Verifies sensitive beneficiary/caregiver context or makes a requested warm introduction.
Conducts the useful relationship-based follow-up, asks what happened and what remains, and identifies affected beneficiary 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 →
SOP taskRevise only when needed or requested
Authenticates beneficiary/caregiver direction, leads affected nonclinical planning, and preserves the prior plan while review is open.
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
SOP taskEstablish the relationship and applicable cadence
Accepts the primary GUIDE relationship, introduces the human contact route, and resolves person-specific cadence or scheduling exceptions.
Selects among already approved eligible navigators, obtains acceptance, and records the replacement assignment when deterministic matching cannot produce an accepted assignment.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.; Only when the approved assignment rule exhausts eligible accepted choices or a documented navigator conflict requires reassignment, and only for a Puerto Rico GUIDE navigator with the approved seniority assignment for this recovery task.Open exact procedure step →
SOP taskPrepare and conduct a qualifying, person-specific contact
Reviews prepared context and personally provides the substantive GUIDE ongoing-support contact.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskAct only on the applicable unmet need or concern
Authenticates the reported need, supports nonclinical choices, and starts the correct nonclinical or clinical handoff without clinical interpretation.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskAgree, document, count, recover, and complete promised work
Confirms understandable next actions, owns the human relationship, authenticates the final contact record, and follows 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 →
Ongoing Monitoring and Support procedure mapUseful contact and material-change branch5 procedure steps
SOP taskPrepare recent promises, results, and known open work
Reviews the prepared source-linked context before the human contact and does not repeat routine data gathering.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskAsk what changed or matters now
Starts with an open, person-specific question and clarifies only what the person raises or what is otherwise specifically due or required.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskCheck plan fit only when the conversation makes it relevant
Shows only the affected plan element, works through nonclinical implications, and starts revision work when actually needed.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskRoute only the real need
Authenticates the report, prepares nonclinical context, and connects the exact receiving lane without deciding protected issues.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskAgree on the next useful action
Explains the next useful action, checks understanding, and remains the human relationship 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 →
24/7 Access procedure mapFrom continuously available human access to truthful follow-through5 procedure steps
SOP taskMaintain a usable, continuously human-covered route
Confirms beneficiaries and caregivers understand the route and remains the nonclinical GUIDE relationship escalation.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskAnswer, recover, and capture the need without clinical triage
Provides relationship-based GUIDE help when the first answer cannot safely or substantively complete the nonclinical need.
SOP taskRecord, share, confirm custody, call back, and carry forward
Accepts nonclinical GUIDE follow-up, conducts the substantive callback when appropriate, and carries the result into ongoing support.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskRecover outages and learn from repeated calls
Reviews repeated-call patterns with the person and determines nonclinical support or contact changes without clinical judgment.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskAnswer a permitted navigation or program question
Provides relationship-based clarification or the required substantive GUIDE service.
Enters when: When the caller requests or materially needs L2 help rather than an approved factual answer.Open exact procedure step →
SOP taskFurnish or hand off the applicable GUIDE support
Provides permitted nonclinical one-on-one caregiver support, navigation, or education reinforcement, or accepts the distinct downstream obligation.
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 mapChoose the exact coordination route and close on a returned result4 procedure steps
SOP taskCoordinate with an outside PCP
Confirms person participation and preferences, frames the nonclinical coordination need, handles relationship exceptions, explains nonclinical next steps, and carries the returned result 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 →
SOP taskRun the specialist referral and return loop
Elicits preferences, supports beneficiary choice, handles relationship and practical barriers, explains coordination steps, and carries forward approved results.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskCoordinate a care-setting transition
Confirms the current situation with the person, elicits immediate nonclinical needs, coordinates logistics, reinforces approved instructions, and follows unresolved work.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskWork another exact clinical coordination dependency
Clarifies the beneficiary's desired result, identifies nonclinical responsibility, coordinates the exact dependency, explains the returned result, and carries forward nonclinical work.
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
SOP taskPrepare factual options and support beneficiary choice
Elicits preferences and barriers and provides relationship-based clarification only when useful or 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 →
SOP taskRelease the referral and arrange the visit
Confirms the chosen recipient and relevant packet, handles relationship or practical barriers, and supports requested introductions.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskObtain the visit result and recommendation
Handles provider-office ambiguity, relationship barriers, or nonresponse not resolved administratively.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskReview, explain, and carry forward the result
Explains nonclinical coordination steps, supports person choices, updates coordination content, and assigns operational follow-through.
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
SOP taskDetect and confirm the current situation
Confirms uncertain current facts with the beneficiary, caregiver, or facility and preserves the person's 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 →
SOP taskContact the person and recover transition records
Asks what happened, what the person understands, what is needed now, and how the team should help; authenticates the source report without clinical interpretation.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskOpen distinct affected work in parallel
Confirms the person wants optional help and initiates distinct nonclinical coordination, referral, appointment, and ongoing obligations.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskReinforce approved instructions and return reviewed results
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 result4 procedure steps
SOP taskComplete the individual community-connection loop
Provides requested choice clarification, sensitive barrier support, warm introduction, and relationship-based follow-through after preparation.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskMaintain a usable service inventory
Reports relationship-sensitive inventory failures or service-seeker barriers without becoming the routine directory researcher.
Enters when: When a person-facing episode exposes a practical or relationship-specific gap.Open exact procedure step →
SOP taskEstablish and operate the AAA/Tribal route
Provides relationship ownership and person-facing support for individual referrals through the established 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 →
SOP taskCoordinate GUIDE with Medicaid HCBS
Coordinates nonclinically with the person and case manager, explains practical responsibility, and addresses preference-sensitive gaps or duplication.
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
SOP taskDefine the need and desired result
Clarifies relationship-sensitive meaning, desired result, and nonclinical barriers after software preparation.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskSearch, verify, and present current factual options
Explains prepared options and tradeoffs or addresses sensitive barriers without choosing for the person.
Enters when: When human clarification or relationship support is requested or materially needed.Open exact procedure step →
SOP taskChoose the option and authorize the appropriate sharing
Provides requested choice clarification, resolves relationship-sensitive ambiguity, or performs a requested warm introduction.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskSend, confirm receipt, and help complete intake
Performs a requested warm introduction or relationship-sensitive intake support.
Enters when: When a human GUIDE relationship act or sensitive barrier remains after preparation.Open exact procedure step →
SOP taskConfirm start and whether the service meets the need
Authenticates the reported result, supports a wanted alternate option, and returns the effect to Care Plan or Ongoing.
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
SOP taskConfirm the trigger and assemble every relevant source
Clarifies source-faithful household use, access, schedule, and practical-barrier reports without reconciling medication.
Enters when: Only when direct confirmation is insufficient or a nonclinical human clarification is required or requested.Open exact procedure step →
SOP taskMatch, compare, pursue missing facts, and prepare the review
Clarifies practical use or access facts without deciding medication intent, safety, equivalence, or regimen.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskPerform reconciliation and author the medication result
Reinforces clinician-approved instructions and practical logistics without changing clinical meaning.
Enters when: When nonclinical explanation or implementation support is needed after the clinician authors the result.Open exact procedure step →
SOP taskWhen changing medication, separate proposal, agreement, choice, and order
Supports the person's preference-sensitive choice and practical logistics without recommending treatment.
Enters when: When human clarification, relationship support, or an approved warm introduction is requested or materially needed.Open exact procedure step →
SOP taskTrack order, pharmacy, possession, instruction, use, and monitoring separately
Provides approved nonclinical schedule, access, teach-back, and practical-use support without reconciling or changing the regimen.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskProvide schedule and access support without choosing treatment
Explains and sets up approved nonclinical schedule, organization, packaging, access, and practical-use 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 →
SOP taskUse the medication-safety bypass
Stops routine nonclinical work, preserves the exact report, and connects the clinical or emergency route without judging urgency.
Enters when: When the concern is first disclosed during L2 navigation or support.Open exact procedure step →
Medication Management and Reconciliation procedure mapMedication source packet to clinician-authored reconciliation result3 procedure steps
SOP taskCompare all source assertions literally
Clarifies actual-use and access reports without deciding regimen intent or safety.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskRecord complete-no-change, complete-with-change, or incomplete
Supports nonclinical explanation, access, and follow-through using the exact clinician-approved result.
SOP taskExplain the reconciled result and remaining uncertainty
Reinforces exact approved information, schedule, access, and practical next steps without adding clinical meaning.
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
SOP taskResolve the pharmacy execution state
Supports person choice and practical access when a nonclinical barrier or pharmacy change arises.
SOP taskSynchronize destinations and give exact final instructions
Reinforces the exact approved instruction and practical schedule without changing the regimen.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskConfirm implementation and complete defined monitoring
Tracks nonclinical use, access, schedule, and support facts and routes concerns without clinical interpretation.
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 result8 procedure steps
SOP taskConfirm applicability—or use the no-caregiver branch
Makes the required reasonable human effort, resolves relationship-sensitive ambiguity, and confirms the nonclinical caregiver 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 →
SOP taskReview assessment, priorities, plan, and available services
Performs the required or requested human review, clarification, relationship support, or sensitive tailoring after software preparation.
Enters when: When ambiguity, distress, comprehension failure, disagreement, accessibility failure, or a human service requirement remains.Open exact procedure step →
SOP taskFurnish skills training and confirm practical application
Conducts the focused human application touchpoint, asks the caregiver to explain or demonstrate intended use, corrects nonclinical misunderstanding, and records remaining needs.
Enters when: Only when the named Puerto Rico navigator's verified subject-specific training competency covers the topic.Open exact procedure step →
SOP taskOffer and provide understandable diagnosis information
Provides the one-on-one approved nonclinical diagnosis-information conversation and routes individualized medical 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 →
SOP taskOffer, arrange, and facilitate support-group participation
Provides the permitted dementia-caregiver facilitation and private nonclinical follow-up.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskFurnish substantive one-to-one support and escalate protected concerns
Provides the substantive nonclinical one-to-one caregiver support, coaching, and agreed 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 →
SOP taskOffer optional support, role coaching, resources, and counseling referral
Provides sensitive preference support, human coaching when sold, warm introduction, and nonclinical boundary support.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskReassess caregiver need and update support
Performs only a required or requested human review, ambiguity resolution, distress support, or relationship-sensitive tailoring.
Caregiver Education and Support procedure mapCaregiver skills training: automated content plus human application5 procedure steps
SOP taskOffer the relevant skills-training route
Provides requested human explanation or relationship-sensitive support without making a clean offer depend on L2 review.
Enters when: When the caregiver requests help or comprehension, accessibility, or relationship issues remain.Open exact procedure step →
SOP taskSchedule and arrange the content and touchpoint
Accepts the assigned human application touchpoint and prepared caregiver context.
Enters when: When the named Puerto Rico navigator's verified subject-specific training competency covers the topic and the task is assigned to that navigator.Open exact procedure step →
SOP taskFurnish the applicable skill content
Provides the permitted human nonclinical application and correction touchpoint.
Enters when: When the named Puerto Rico navigator's verified subject-specific training competency covers the topic and the task is assigned to that navigator.Open exact procedure step →
SOP taskRoute individualized clinical or safety judgment
Stops the nonclinical training route, captures the concern source-faithfully, and connects the authorized professional.
Enters when: When the named Puerto Rico navigator is performing the training task within verified competency or receives the question.Open exact procedure step →
SOP taskConfirm practical understanding and intended use
Conducts the focused non-shaming application check, corrects general nonclinical misunderstandings, and records remaining needs.
Enters when: Only when the named Puerto Rico navigator's verified subject-specific training competency covers the topic.Open exact procedure step →
Caregiver Education and Support procedure mapNo-caregiver branch: stop caregiver services, continue beneficiary safeguards2 procedure steps
SOP taskMake a reasonable effort to identify a caregiver
Makes the reasonable human effort to identify a caregiver and records the person's circumstances without inventing a relationship.
Enters when: No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active.Open exact procedure step →
SOP taskOpen and follow the added beneficiary safeguards
Provides direct nonclinical navigator contact and arranges practical beneficiary 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.