Clickable procedure map
Eight-pillar episode system A longitudinal service map—not an eight-step pipeline. Select a seam or worked episode to see the nested sequence and its controlling source.
Every person or outside party resolves through the canonical actor directory and is paired with the work performed in this step. Software and records stay separate. Open people and software directory → Non-executable overview. This map routes work into the triggered procedure; it is not a chronological claim that every lane or person enters the episode. Each action links its exact task to the same canonical job role, participation category, or outside-party type; a different task never creates a different role.
START / REJOIN Begin with an attributable result or an accepted action; lateral entries and evidence controls do not become later chronological steps.
Follow every applicable branch
DECISION 01 What owning work should receive this result? Furnish the distinct service
↙ Affected assessment domain Open only the affected assessment work and return its result. open subprocess Receiving procedure Comprehensive Assessment procedure Assign the exact nonclinical or licensed task inside the nested procedure.
Continue to decision: return ↓ ↓ Accepted plan action or plan mismatch Open the accepted action or bounded Care Plan revision. open subprocess Receiving procedure Care Plan procedure Assign the exact planning or protected clinical task inside the nested procedure.
Continue to decision: return ↓ ↓ Distinct service need or unfinished promise Open the owning service; do not claim completion from the feed. open subprocess Receiving procedure Owning pillar procedure Assign the exact canonical role and task in the receiving SOP.
Continue to decision: return ↓ ↘ Context only or no downstream work Retain permitted context or close the feed without an acceptance gate. complete REACHED ONLY FROM owning-work: Affected assessment domain · owning-work: Accepted plan action or plan mismatch · owning-work: Distinct service need or unfinished promise
Choose the one supported outcome
DECISION 02 Did the owning service return a real result and next useful action? Return the result and the next useful action
Open the complete text procedure outline The outline preserves every source-bound review step. The decision flow above controls which action occurs and whether it stops, loops, escalates, or rejoins.
01 Establish an attributable baseline 02 Convert accepted choices into owned actions Human assignment decision needed · 1 affected act SOP DESIGN BLOCKED — do not execute the affected work · Controlled by O-PA-001, O-003 03 Offer the configured Proxi companion interaction Open nested procedure 04 Furnish the distinct service 05 Handoff is not completion Human assignment decision needed · 1 affected act SOP DESIGN BLOCKED — do not execute the affected work · Controlled by O-PA-001, O-008, O-021 Open nested procedure 06 Return the result and the next useful action 07 Attribute distinct services; count labor once Open nested procedure 08 Enter laterally through 24/7 Open nested procedure 09 Handle post-discharge medication confusion Open nested procedure 10 Respond to caregiver exhaustion or possible breakdown Open nested procedure Selected source-bound action
Establish an attributable baseline
Action Complete the applicable initial, annual, or affected-domain assessment work and preserve unknown or blocked facts.
Documentation and closure evidence Assessment result, contributors, provenance, unresolved facts, and exact receiving obligations. 01 Canonical job roles and their tasks in this source step 4 role-task traces; conditions determine which one actually enters L2 Puerto Rico GUIDE navigator
Work performed in this step 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.
When this person enters Only for assigned nonclinical assessment domains or when the person requests or requires a human relationship, clarification, or accessibility route. L3-RN U.S. clinical support RN
Work performed in this step Reviews the prepared nursing domains, performs the assigned function, symptom, safety, and medication-use assessment, documents findings and the nursing disposition, and escalates questions requiring higher medical authority.
When this person enters Only when the assessment assigns nursing, function, symptom, safety, transition, or medication-use work within beneficiary-location authority. L3-Behavioral U.S. LCSW or behavioral clinician
Work performed in this step Reviews the prepared behavioral, psychosocial, distress, and safeguarding domains, performs the assigned assessment, documents findings and the behavioral disposition, and escalates any immediate or higher-authority concern.
When this person enters Only when an assigned behavioral, psychosocial, distress, or safeguarding domain requires this profession. L4 U.S. prescribing or Part B E/M clinician
Work performed in this step Reviews the prepared examination and medical questions, performs the required examination, staging, diagnosis, treatment, or prescribing decision, signs the resulting finding or order, and returns the medical disposition to the attributable assessment record for the next routed action.
When this person enters Only when the assessment requires examination, staging, diagnosis, treatment, prescribing, orders, or another L4 medical act. 02 Beneficiary, caregiver, authority, and outside-party participation 2 linked touchpoints; none is a Proxi employment role People served Beneficiary Canonical participation category: Beneficiary
Participation, input, receipt, or outside work 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.
When this person or outside party enters No narrower actor-specific condition is recorded; this assignment applies only when the selected procedure step is active. People served Caregiver Canonical participation category: Caregiver or authorized representative
Participation, input, receipt, or outside work Supplies separately attributed caregiver observations and needs, corrects the caregiver summary, and identifies unresolved concerns without substituting caregiver report for beneficiary fact or clinical judgment.
When this person or outside party enters Only when a caregiver participates under current permission; caregiver observations remain separately attributed. 03 Automated preparation and control 3 uses of the five canonical software services; these are functions, not roles 04 Records, evidence, and next work 2 source-linked record functions assessment baseline result. Attributable initial, annual, or affected-domain result with contributor identity and provenance.
assessment unknowns limitation. Unresolved, refused, stale, conflicting, or blocked facts that remain visible.
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Viewing Assessment → Care Plan → distinct service work → Ongoing return. Overview open.
Eight complete pillar maps
Every source task belongs to a visible phase. Select a pillar to open its task-complete phase map and nested high-risk procedure.
01 49 tasks
Comprehensive assessment All 49 tasks partitioned into eight source-bound phases, with urgent and dependency branches kept visible.
Open pillar sequence → 02 52 tasks
Person-centered care plan All 52 tasks partitioned from participation through action execution and revision.
Open pillar sequence → 03 37 tasks
Ongoing monitoring and support All 37 tasks partitioned around a useful contact, exact follow-through, and material-change routing.
Open pillar sequence → 04 29 tasks
24/7 access All 29 tasks partitioned across readiness, the live human-answer episode, follow-through, and service recovery.
Open pillar sequence → 05 63 tasks
Care coordination and transitions All 63 task titles partitioned into the four materially different source-defined routes.
Open pillar sequence → 06 57 tasks
Referral and services supports All 57 tasks partitioned across individual connection, inventory stewardship, AAA/Tribal, and Medicaid HCBS work.
Open pillar sequence → 07 38 tasks
Medication management and reconciliation All 38 tasks partitioned from source preparation through prescribing judgment, execution, support, and safety.
Open pillar sequence → 08 34 tasks
Caregiver education and support All 34 tasks partitioned across applicability, training, information, support, referral, and learning return.
Open pillar sequence →