Care coordination and transitions

Status: DETAILED MEDICAL OPERATING SOP DRAFT — human-readable clinical workflow; not yet clinically or operationally approved

CMS baseline: GUIDE RFA Appendix B, Section 5 ↗. The Proxi column identifies candidate automation, not functionality already deployed. The executed GUIDE Participation Agreement remains the final requirements check before these tasks are used in the field.

In Person required?, Yes means a person must perform or own the task, Partial means Proxi can perform substantial preparation or routine execution but a person must validate, decide, authorize, or handle exceptions, and No means Proxi can perform the task after the necessary access and approved instructions are in place.

Medical SOP purpose and scope#

This SOP turns the task inventory below into the clinical operating sequence for four kinds of work:

1. coordination with a beneficiary's PCP when the PCP is outside the GUIDE care team;
2. referral to and closed-loop coordination with a specialist or other clinical provider;
3. support during a transition between the beneficiary's residence and a hospital, emergency department, nursing facility, hospice, or another care setting; and
4. other clinical coordination needed to manage dementia or a co-occurring condition across the care continuum.

Community-resource and Medicaid HCBS connection work is detailed separately in 15_SOP_Referral_and_Services.md. A safety concern is an interrupt to any coordination route, not a separate referral type.

CMS establishes the Section 5 obligations. The handoff packet, role sequence, teach-back practice, proposed 48-to-72-hour recovery contact, and detailed closure criteria below are Proxi clinical operating design informed by AHRQ transition-safety guidance; they are not additional CMS requirements. Numeric operating clocks remain proposed until O-004 is approved.

Proxi supplies or contracts the assigned labor under the validated Participant and Partner Organization arrangement. The enrolled GUIDE Participant retains nondelegable responsibility for the care-delivery requirement, care-team composition and supervision, clinical quality, disclosure controls, and supporting evidence. External PCPs, specialists, facilities, pharmacies, and emergency services retain responsibility for the acts only they can furnish. Proxi may request, coordinate, prepare, transmit after the required release, and track; it cannot assign or attest an external party's clinical act.

Authority and role assignment#

The Puerto Rico L2 navigator operation performs no licensed assessment, triage, reconciliation, treatment decision, or individualized clinical instruction. Every such act routes to the separate U.S. clinical workforce. Before that professional acts, confirm the beneficiary's current physical location and the professional's current authority for that jurisdiction and act. If location or authority is unknown, L0-L2 may collect facts and connect the person, but no clinical decision or new instruction may be given through that route. An immediate safety pathway must not be delayed for routine intake questions.

Cross-pillar preparation, no-repeat handoffs, owner acceptance, and shared labor follow 25_GUIDE_Eight_Pillar_Service_Integration.md. Preparation precedes judgment: software and L1 assemble the source-linked packet; L2 enters only under D-021; and a prepared protected question goes directly to the authorized U.S. professional.

Required coordination record#

Every clinical coordination episode must begin with a focused record that contains, as applicable:

• beneficiary identity, current physical location, current care setting, preferred language and communication accommodations;
• reporter identity, decision or disclosure authority when relevant, callback information, and beneficiary preferences for caregiver participation;
• coordination route, trigger, date and source, specific requested outcome, and why the work is needed now;
• current PCP, relevant specialists, prescribing clinicians, facility or agency contacts, and evidence of each current relationship;
• the exact clinical question or requested action, written by or confirmed with the clinician when medical judgment is involved;
• relevant diagnoses and conditions as documented by their sources, current symptoms or observable changes reported verbatim, and the person's cognitive, functional, and behavioral baseline when material;
• current care-plan reference, beneficiary goals and preferences, and only the care-plan content relevant to the recipient and purpose;
• medication and allergy information relevant to the coordination question, clearly distinguishing reconciled regimen, reported use, and unresolved discrepancies;
• recent encounters, transition information, pending tests or results, follow-up appointments, equipment, home services, and known barriers when applicable;
• every source, author, event date, receipt date, correction, and unresolved conflict; and
• requested response, responsible reviewer, return route, and clinically assigned timing.

Unknown, stale, or conflicting information remains labeled as such. A focused clinical packet is not a full-chart dump. AI-generated summaries remain aids; the original records and source-linked facts accompany any clinical review.

Universal safety interrupt#

If a beneficiary, caregiver, provider, or record raises a possible immediate safety issue, new or worsening symptom, medication problem, abuse or neglect concern, behavioral-health crisis, conflicting clinical instruction, or request for urgent medical advice:

1. L1 or L2 captures the report verbatim, confirms callback information and current location when safely obtainable, and stops ordinary advice or transmission.
2. The approved clinical or emergency pathway is invoked. L1, L2, and AI do not determine urgency, causality, treatment, or disposition.
3. An L3 professional may assess or triage only within beneficiary-location authority and approved scope. L4 or the applicable treating clinician makes medical and treatment decisions; emergency services handle immediate threats.
4. Failed connection is actively escalated; an attempted call is not a completed handoff.
5. The safety disposition and resulting work are recorded separately. Completing the safety handoff does not close the underlying coordination, transition, or medication obligations.

Procedure A — outside-PCP coordination#

1. Confirm the PCP and team relationship. Verify the current PCP, practice, effective relationship, and whether the PCP is outside the GUIDE care team. Unknown membership does not default to outside or inside.
2. Complete the standing GUIDE duties. Confirm the beneficiary's communication preferences and restrictions, verify the PCP endpoint, and prepare the GUIDE participation notice and current care plan for authorized release. Confirm meaningful access to the current plan; a dormant portal, failed transmission, or superseded plan is insufficient.
3. Avoid unnecessary PCP work. Notice, current-plan access, and future plan revisions are standing duties. A stable month does not require an additional PCP call when no specific coordination need exists.
4. Define the need-specific request. When an actual coordination need exists, L0/L1 assembles the source-linked need, beneficiary/caregiver's literal requested result, supporting facts, conflicts, prior attempts, and a draft exact question. A clear nonclinical choice may be confirmed directly. L2 resolves only requested or relationship-dependent ambiguity. L3/L4 validates or changes the clinical question, determines clinical urgency, and exercises the protected judgment; the clinician does not gather the routine supporting record.
5. Prepare and release the focused packet. Proxi verifies the recipient and assembles the exact approved content. Under V1, an authorized human releases the packet. Proxi may not substitute a recipient, purpose, channel, or content after authorization.
6. Track the response without interpreting it. L0 tracks; L1 pursues administrative nonresponse and records replies verbatim. L1 stops when the reply contains a clinical question, contradiction, new instruction, dispute, or safety concern.
7. Obtain authorized review. Route clinically material information to the professional whose scope covers the question. Receipt is not acceptance, and recency alone does not resolve conflicting clinical positions.
8. Communicate and carry forward. The clinician explains clinical conclusions; L2 explains logistics and reinforces approved content. Update the care plan or record an authorized reviewed-no-change conclusion, assign every resulting action, and preserve unresolved disagreement.

Outside-PCP foundation — detailed task cards#

These four tasks establish the person, team relationship, communication choices, and usable destination before Proxi prepares the GUIDE notice or current care plan. They are event-driven rather than monthly work. Reopen the affected task when the beneficiary, PCP, care-team roster, participation preference, or routing information changes, becomes stale, conflicts with another source, or fails in use.

The evidence labels below describe what a source actually proves:

• Direct evidence establishes the narrower fact the source records. For example, a Medicaid or managed-care PCP field can directly establish the payer's administrative assignment and effective date, but it does not by itself establish whom the beneficiary regards as the current treating PCP.
• Corroborating evidence supports or challenges a candidate fact but cannot establish that fact alone. Claims establish dated utilization by the named billing or rendering provider, not a current PCP designation.
• Identity-only evidence helps identify or contact a provider. It does not establish a beneficiary relationship, payer assignment, GUIDE-team membership, permission, or a current clinical endpoint.

The labor estimates are provisional Proxi workload-calibration assumptions, not CMS requirements, service clocks, staffing guarantees, or field observations. Clean-path minutes are expected Proxi human labor; automated processing time and beneficiary, representative, practice, or payer time are excluded. All four foundation tasks can be zero Proxi human minutes when current sources yield a prepared candidate packet, the beneficiary/representative supplies a clear authenticated confirmation directly, and the practice-managed endpoint is current. When manual PCP identity, roster, contact, or routing resolution is actually required, use one shared 13-minute Philippines administrative exception allowance for the outside-PCP foundation episode rather than adding 13 minutes to each failed task. L2 time exists only for required/requested human service, ambiguity, disagreement, distress, accessibility failure, no-PCP relationship work, or useful confirmation; it is not a default validation charge. Replace all assumptions with measured pilot data.

Confirm the current PCP#

When. Complete at initial coordination setup; whenever PCP information is missing, conflicting, stale, or reported changed; after a transition that may have changed the primary-care relationship; and before the first outside-PCP GUIDE notice or care-plan exchange.

What and how much. Establish one truthful outcome: (1) current PCP confirmed, including the individual clinician and practice; (2) the beneficiary currently has no PCP; or (3) unresolved. An unresolved result keeps this task open and does not default to the provider seen most often.

Data inputs.

• Direct: the current statement of a capable beneficiary; a representative acting under established authority; authenticated confirmation from the PCP practice; or a current authoritative clinical record that explicitly designates the clinician as PCP. A state or managed-care PCP assignment record is direct only for the administrative assignment it records, not for the beneficiary-identified or actual treating relationship (SRC-NC-MEDICAID-PCP-ASSIGNMENT).
• Corroborating: beneficiary-authorized payer claims, encounters, and payer-maintained clinical data (SRC-CMS-PATIENT-ACCESS-API); Medicare Parts A, B, and D claims available through beneficiary-authorized Blue Button 2.0 (SRC-CMS-BLUE-BUTTON); recent primary-care encounters; referrals; orders; care plans; and HIE records. These can identify candidates or conflicts but do not select the current PCP by frequency.
• Identity-only: NPI/NPPES, licensure records, payer provider directories, public practice websites, maps, addresses, and phone listings (SRC-CMS-NPI-FACT-SHEET; SRC-CMS-PROVIDER-DIRECTORY-API).

Potential Proxi work. With the required access and beneficiary authorization, pull candidate PCP data from payer, claims, EHR, HIE, and directory sources; retain each source and as-of date; normalize clinician, NPI, practice, and alias information; present the candidates for confirmation; record corrections; and route unresolved conflicts. Proxi must keep payer-assigned PCP, beneficiary-identified PCP, and observed treating providers as separate facts.

Human role. The beneficiary or properly authorized representative supplies or confirms the relationship after software presents the source-linked candidates. No Proxi human is needed for a clear authenticated confirmation. L1 Philippines support performs administrative candidate cleanup or manual office verification only when the shared exception is triggered. L2 enters only when the person requests human help or ambiguity, disagreement, distress, accessibility failure, a no-PCP relationship problem, or relationship-dependent coordination remains. Software applies the approved representative-authority and disclosure rule. Missing identity or office facts return to L1; missing preference, relationship, or permission facts return to L2. Only a complete verified fact pattern that exposes a genuine legal-authority question not answered by the approved rule routes to Healthcare Legal Counsel under O-021, while the affected act remains held.

Provisional clean-path Proxi human time. 0 Puerto Rico navigator minutes for a clear authenticated direct confirmation. Use the shared 13-minute Philippines administrative exception only when administrative PCP-identity or manual-contact resolution is triggered; add L2 only for the human-entry conditions above.

Completion evidence. Record the outcome; clinician and practice; NPI when available; as-of and confirmation dates; confirming person and their authority; sources considered; and the disposition of every conflicting PCP candidate. A confirmed no-PCP outcome is truthful completion of this fact-finding task but does not establish an outside-PCP duty.

What does not prove completion. A recent claim, payer assignment alone, prescribing clinician, hospital attending, directory result, old EHR field, practice address, unanswered outreach, or a model-generated “most likely PCP.”

Confirm whether the PCP is outside the GUIDE care team#

When. Complete immediately after the current PCP is confirmed and repeat when either the PCP identity or GUIDE care-team membership changes.

What and how much. Produce one determination: inside the GUIDE care team, outside the GUIDE care team, or not yet determined. Unknown does not default to inside or outside.

Data inputs.

• Direct: the confirmed PCP identity and the Participant's authoritative current GUIDE practitioner roster or authenticated Participant confirmation of team membership.
• Corroborating: EHR care-team designations, Participant scheduling records, enrollment documentation, and organizational affiliation.
• Identity-only: NPI/NPPES, licensure, public or payer directories, practice address, group affiliation, and claims. These may improve identity matching but do not establish GUIDE-team membership.

Potential Proxi work. Normalize the PCP and roster identities; compare unique identifiers; identify aliases, practice changes, and same-name/different-provider cases; record the roster's effective date; and repeat the comparison after an authoritative PCP or roster change.

Human role. No Proxi human is needed for an exact unique-identifier match against an authoritative current roster. L1 or the Participant's operations owner resolves missing identifiers, stale rosters, ambiguous identities, or disputed membership; L2 owns any resulting beneficiary coordination.

Provisional clean-path Proxi human time. 0 minutes. Use the shared 13-minute Philippines administrative exception only when manual roster or identity resolution is triggered.

Completion evidence. Record the PCP identifier, authoritative roster source and effective date, match result, and the source and disposition of any human resolution.

What does not prove completion. Failure to find a name, a different address or organization, absence from an EHR screen, a claim from outside the Participant, or comparison against a stale or incomplete roster.

Confirm participation and communication preferences#

When. Complete during the first coordination interaction; before using a new channel or involving a caregiver or representative; and whenever preference, capacity, authority, language, accessibility, safety, or contact information changes.

What and how much. Create one current participation profile covering how the beneficiary wants to participate; preferred and fallback channels; language and accessible format; safe contact times and voicemail or message restrictions; who the beneficiary wants included and for what purpose; and explicit do-not-contact or disclosure restrictions. Preference and legal disclosure authority remain separate: asking to include a daughter records a preference but does not by itself settle the permission basis under O-021.

Data inputs.

• Direct: current choices expressed by the beneficiary; choices made by a representative acting within established authority; current communication restrictions; and applicable authorization or representation records.
• Corroborating: prior successful communication, care-plan preferences, documented language and accessibility needs, and prior navigator notes.
• Identity-only: emergency-contact fields, caregiver lists, portal-proxy records, payer contact records, phone numbers, and email addresses. These identify a possible contact but do not establish current preference or disclosure authority.

Potential Proxi work. Conduct an accessible text, voice, or portal interview; explain each option in plain language; read the resulting profile back; accept corrections; retain the source and date; apply explicit channel restrictions; send missing administrative facts to L1 and preference, relationship, or permission facts to L2; and re-evaluate the approved rule after correction. Proxi does not decide capacity or legal authority. A complete verified fact pattern that the approved rule does not cover holds only the affected act; only a genuine unresolved legal-authority question routes to Healthcare Legal Counsel.

Human role. The beneficiary or properly authorized representative makes the choices directly after software presents the current profile for confirmation. No Proxi human is needed on a clear accessible path. L1 Philippines support may perform bounded contact cleanup under the shared administrative exception. L2 enters only for a required/requested human conversation, inaccessible automation, ambiguity, conflicting wishes, distress, family disagreement, or relationship-dependent clarification. Software applies the approved identity, permission, recipient, purpose, content, channel, and restriction rule. Missing facts return to L1 or L2 according to the fact; only a complete verified fact pattern that exposes a genuine unresolved legal-authority question routes to Healthcare Legal Counsel. Possible decision-specific capacity questions route directly to the authorized clinician or Healthcare Legal Counsel rather than through L2.

Provisional clean-path Proxi human time. 0 Puerto Rico navigator minutes. Use the shared 13-minute Philippines administrative exception only for bounded manual contact cleanup; add navigator or clinical time only when its specific entry condition occurs. Healthcare Legal Counsel time is event-driven only for a genuine uncovered legal-authority question, not for routine disclosure-rule application.

Completion evidence. Record the current participation profile; who supplied it and their authority when applicable; confirmation date; communication and disclosure restrictions; accessibility needs; and any unresolved authority issue as a separate open matter.

What does not prove completion. Prior message delivery, silence or lack of objection, a caregiver possessing the phone, an emergency-contact designation, portal access, an old preference, or payer demographics.

Verify PCP routing information#

When. Complete after PCP and practice identity are confirmed and before the first GUIDE notice or care-plan release. Reopen after failed delivery or whenever the practice, department, endpoint, accepted document type, or channel changes.

What and how much. Verify at least one accepted route for the GUIDE participation notice and at least one route capable of providing meaningful access to the current care plan. The same endpoint may satisfy both only when the practice confirms that it accepts both content types.

Data inputs.

• Direct: authenticated confirmation from the receiving practice or records department identifying the exact department, endpoint, channel, and accepted document type; or a current practice-managed clinical-routing record.
• Corroborating: Participant EHR directories, HIE or Direct directories, payer Provider Directory API results, recent referral responses, and prior successful exchanges (SRC-CMS-PROVIDER-DIRECTORY-API). These are candidates for verification, not proof that the current endpoint accepts this packet.
• Identity-only: NPPES addresses and phone numbers, claims billing addresses, public websites, general switchboards, search results, and commercial fax listings (SRC-CMS-NPI-FACT-SHEET).

Potential Proxi work. Aggregate and normalize candidate phone, fax, electronic, and mailing endpoints; compare sources and dates; detect conflicts, changed destinations, and bounces; present the selected route for verification; retain the verification response; and reopen the task after delivery failure. Packet authorization and release remain separate work under O-021.

Human role. No Proxi human is needed when an authenticated current practice-managed route exists and matches the confirmed PCP and content type. L1 records/coordination support verifies uncertain routes with the practice and resolves discrepancies. Software separately applies the approved recipient, purpose, content, channel, permission, and restriction rule. Under D-007, any V1 human-release act remains SOP DESIGN BLOCKED — NOT OPERATIONAL until O-021 names its actual canonical performer; endpoint verification does not authorize disclosure. Only a genuine uncovered legal-authority question routes to Healthcare Legal Counsel.

Provisional clean-path Proxi human time. 0 minutes. Use the shared 13-minute Philippines administrative exception only when manual endpoint resolution is triggered. This estimate excludes the separate V1 human-release act; that act cannot run until O-021 names its actual canonical performer.

Completion evidence. Record the matched PCP and practice, receiving department, endpoint and channel, accepted content type, verification source, named confirming party when applicable, verification date, and fallback route.

What does not prove completion. A valid-looking fax number, fax transmission success, absence of an electronic bounce, prior use of the endpoint, a general office number, claims address, or directory listing. Routing verification also does not prove that the GUIDE notice was delivered or that the PCP obtained meaningful access to the current care plan.

Procedure B — specialist or other clinical-provider referral#

1. Prepare the referral-decision packet. L0/L1 retrieves and organizes the reported need, relevant current records, prior referrals/results, contradictions, current location, coverage and access facts, and a draft clinical question. Software presents known location, language, accessibility, modality, schedule, transportation, caregiver, and other constraints for direct beneficiary/caregiver confirmation rather than asking a navigator to gather them again.
2. Establish the clinical branch and practical choice. A qualified clinician reviews the prepared packet and determines whether referral is clinically appropriate, degree of urgency, provider type, question to be answered, and required return result. RFA §5.2 permits this referral branch; it is not mandatory for every beneficiary. Software/L1 verifies directory and availability facts. The beneficiary may make a clear prepared choice directly; L2 enters only for requested help, ambiguity, disagreement, distress, accessibility failure, warm introduction, or relationship-dependent practical fit. Clinical suitability stays with L3/L4/L5.
3. Identify the PCP obligations. Determine the current PCP and whether active co-management exists. Unknown is not no. Prepare the required PCP referral notice and, when the PCP is actively co-managing, the clinically appropriate consultation.
4. Obtain any lawful order or authorization. The authorized clinician creates any required referral order. L0/L1 handles coverage and administrative documentation without creating clinical content.
5. Prepare the referral packet for authorized release. Include the exact clinical question, pertinent source-linked facts, relevant care-plan content, requested response, and return route. Optional notice to the specialist and optional care-plan sharing remain distinct from mandatory PCP notice.
6. Complete a requested introduction. When requested by the beneficiary or GUIDE caregiver, an approved care-team member makes a human-authored introduction to the new provider through the approved modality after the separate disclosure basis and exact content are confirmed. This is distinct from transmitting the referral and need not be a synchronous three-way call unless policy requires it.
7. Support access. Schedule, address practical barriers, and confirm the disposition. An appointment date is not an encounter, and an encounter claim is not correctly matched clinical documentation.
8. Retrieve the result. After an encounter, obtain the correctly matched visit documentation and any recommendations or changes. Partial, illegible, wrong-patient, wrong-encounter, unsigned, or internally inconsistent material does not satisfy the return obligation.
9. Reconcile the clinical result. The authorized clinician compares the returned recommendation with the current care plan, medication regimen, PCP plan, other specialist positions, beneficiary goals, and current circumstances. Conflicts remain withheld from instruction until resolved by the proper authority.
10. Explain and execute the next plan. The clinician explains findings and medical decisions; L2 explains coordination steps, supports beneficiary choice, and uses teach-back for reviewed instructions. L2 records and routes every clinician-authorized follow-up to its established internal owner and coordinates execution; L2 does not authorize clinical work or assign responsibility to an external party.
11. Close truthfully. Apply the successful or non-success criteria below. Referral rejection, scheduling, a safety handoff, or exhausted administrative attempts do not by themselves establish successful closed-loop completion.

Procedure C — transition between residence and a care setting#

1. Classify the transition factually. Confirm the from/to settings, unit or level of care when known, transition direction, event and awareness dates, current location, expected duration, and whether another transition is planned. Do not infer RCC, memory-care, hospice-benefit, or long-term-nursing status from a facility name.
2. Begin support even when records are missing. Missing discharge information is not evidence of no change. L0/L1 immediately pursues and organizes available records, prior instructions, known supports, missing items, and candidate current needs. An urgent or required live-human route begins immediately while preparation continues in parallel.
3. Confirm only what sources cannot establish. Present the prepared transition facts to the beneficiary or permitted caregiver and ask them to confirm, correct, and supply what happened, what they understand, current lived needs/supports, and how they want Proxi to help. L2 joins only for a required/requested human recovery conversation, ambiguity, distress, disagreement, accessibility failure, or relationship-dependent barrier. For discharge home, the proposed Proxi target is a recovery contact within 48 to 72 hours, informed by AHRQ RED; this is not a CMS deadline and remains subject to O-004.
4. Obtain the transition packet. Seek the discharge or transfer summary, instructions, medication lists and orders, diagnoses as documented by the treating source, pending tests and results, follow-up appointments, warning signs supplied by clinicians, equipment, home-service orders, dietary or activity instructions when material, and responsible contacts.
5. Perform clinical and psychosocial review when triggered. Software/L1 builds the structured source-faithful transition report from records and direct beneficiary/caregiver statements, preserving missing and conflicting facts. The prepared packet routes directly to L3 when symptoms, change from baseline, safety concerns, medication discrepancy, psychosocial or safeguarding concern, unreliable information, or a clinically designated high-risk transition is present. L4/L5 enters for medical decisions. L2 is not a clinical gateway and supplies only genuinely needed relationship context. Routine stable transitions do not require automatic licensed review unless Proxi explicitly adopts that broader clinical-service design.
6. Complete the linked medication work. Compare pre-transition regimen, facility administration, discharge orders, pharmacy events, household supply, and reported current use. Merely opening the Medication Management case is insufficient; the route-specific authorized clinician must produce the applicable reconciliation outcome.
7. Assign every pending clinical result. Record each pending test, laboratory result, imaging result, pathology result, specialist recommendation, or other unresolved clinical item; name who will obtain it, who is clinically responsible for reviewing it, how the result returns, and what happens if it does not arrive.
8. Make follow-up executable. Confirm the purpose, responsible clinician, date or scheduling need, location, modality, transport, interpretation, accessibility, and required records for each follow-up visit or test.
9. Confirm equipment, services, and basic supports. Verify delivery and usability of ordered equipment and home services and address food, transportation, personal care, housing, caregiver, and other practical needs through the appropriate Proxi service.
10. Obtain higher-authority clinical disposition. L4 or the applicable treating clinician resolves new symptoms, conflicting instructions, unclear treatment ownership, clinical deterioration, medication decisions, or a need to alter the medical plan.
11. Communicate with teach-back. Provide an accessible, clinician-approved recovery summary covering the current plan, medication instructions, follow-up, pending results, equipment and services, and the approved route for problems. Ask the beneficiary or permitted caregiver to explain the plan back in their own words; re-explain and add support when understanding remains incomplete.
12. Follow through. Confirm medication access and reported implementation, appointments, results, equipment, home services, caregiver availability, and whether new problems or another transition occurred. A new transition starts linked work without erasing the prior episode.
13. Reconcile the care plan. Update current setting, providers, responsibilities, services, goals, and accepted clinical recommendations, or record an authorized reviewed-no-change conclusion.
14. Close only when the transition criteria below are met. A clinically safe provisional plan may allow immediate care to continue, but it does not prove that missing records, medication, results, equipment, services, or communication obligations are complete.

Procedure D — additional clinical coordination#

1. Define the unmet need, beneficiary's desired result, and whether the need is factual, practical, clinical, behavioral, privacy-related, or mixed.
2. Identify the person or organization with actual authority and practical ability to act; do not assign an external clinician unilaterally.
3. Obtain clinical definition and urgency from the appropriate licensed professional when needed.
4. Assemble and release a focused packet through the approved process, track the response, and route the returned content without interpreting it administratively.
5. Obtain the authorized disposition, explain it through the correct role, update the care plan when needed, and assign every resulting task.

Proposed timing and escalation#

Objective completion criteria#

Cross-pillar coordination feeds#

This SOP participates in cross-pillar episodes under 25_GUIDE_Eight_Pillar_Service_Integration.md. Care Coordination receives service attribution only for a returned outside response, working care handoff, completed transition obligation, or truthful unresolved external dependency that the correct owner reviewed and carried into ongoing care. A request sent, appointment booked, record received, or owner assigned is not the result by itself.

One provider call or transition conversation may satisfy several coordination tasks and feed several pillars. Count its shared preparation, call, and documentation minutes once; record later clinician, pharmacy, referral, or service-delivery acts once in their owning work.

Documentation and audit record#

The coordination record must show:

• trigger, route, identity, current location, beneficiary/caregiver participation, and applicable authority facts;
• source-linked facts and unresolved conflicts presented to each human reviewer;
• clinical question, clinician identity, credentials, beneficiary-location authority, decision, and rationale where clinical judgment occurred;
• exact recipient, purpose, approved content, releasing human, channel, release time, and delivery/receipt/access evidence for every outbound PHI packet;
• every attempt, response, appointment, encounter, returned document, and reconciliation result without treating one as another;
• beneficiary choice, refusal, requested introduction, explanation, accessibility support, and teach-back result;
• care-plan and medication effects, pending-result ownership, follow-up assignments, and new linked work; and
• the route-specific successful or non-success outcome and the evidence supporting it.