Eight-pillar service integration

Status: provisional authoritative project draft for clinical, compliance, privacy, legal, operational, finance, and program-owner review. It coordinates the eight existing service SOPs but does not settle an open decision, establish field-delivery authority, or prove that any described capability is deployed.

Scope: the eight non-respite GUIDE service pillars in the Proxi operating design:

1. Comprehensive Assessment — initial, annual, and bounded reassessment;
2. Person-Centered Care Plan;
3. Ongoing Monitoring and Support;
4. 24/7 Access;
5. Care Coordination and Transitional Care;
6. Medication Management;
7. Referral and Coordination of Services and Supports; and
8. Caregiver Education and Support.

The controlling source order remains the project source-of-truth order. This manual coordinates the existing SOPs; it does not replace their authority, evidence, timing, task, completion, or human-minute rules.

1. Purpose and non-negotiable boundary#

This manual explains how one real beneficiary or caregiver episode can move through several GUIDE services without:

• making the person repeat facts already supplied;
• dropping a low-information, conflicting, corrected, or late fact;
• treating a handoff as the receiving service;
• counting one human interaction several times;
• making Ongoing Monitoring into a recurring mini-assessment;
• allowing Care Plan to absorb Assessment or another service's protected act;
• allowing software or AI to become the clinical, legal, eligibility, payment, routing, closure, or escalation decision maker; or
• creating person-facing work merely to fill a billing month.

AI and software may collect, retrieve, compare, organize, preserve source distinctions, prepare choices, draft bounded content, form the exact unresolved question, and track accepted work. Deterministic approved rules control known workflow obligations, permissions, routing, deadlines, and escalation. The beneficiary or caregiver makes their own choices within established authority. The licensed or otherwise authorized human performs every protected judgment or human service required for the act. External organizations decide and perform only the acts they control.

This is a shared semantic procedure. Each pillar's authoritative SOP controls whenever this manual and a pillar-specific rule appear to differ.

2. The eight pillars and their independent results#

Each pillar is independently meaningful and independently closable. A common episode can join their work, but no pillar becomes a mere subtask of another.

3. The longitudinal spine#

The eight pillars operate around one continuing loop:

Comprehensive Assessment establishes the source-attributed baseline and explicit unknowns. Care Plan turns applicable findings and person choices into actions. The other pillars perform their distinct services and return real results. Ongoing Monitoring and Support is the longitudinal return engine: it maintains the human relationship, follows promised results, and detects a relevant change or unresolved baseline fact. Only the affected Assessment domain, Care Plan element, or downstream service reopens. The annual Comprehensive Assessment remains due on its own schedule even when Ongoing reports stability.

3.1 Comprehensive Assessment remains first-class#

Comprehensive Assessment includes three different occasions:

• Initial Assessment: establishes the first current GUIDE baseline under the applicable Assessment SOP.
• Annual Assessment: remains due under its own approved timing rules. Stable Ongoing contacts do not waive it.
• Bounded reassessment: reopens only the affected domain or domains when a supported change, stale/conflicting fact, late correction, invalid prior result, or authorized clinical need requires renewed Assessment work. “Bounded reassessment” is Proxi operating language; it must not be represented as a new CMS category or used to invent timing.

Assessment completion does not depend on Care Plan completion. Care Plan acknowledgement of an Assessment handoff does not make Assessment subordinate to Care Plan. Conversely, plan revision or Ongoing discussion does not substitute for an annual or otherwise applicable Assessment act.

Under D-018, unresolved information stops only the work that actually depends on it. Independent, authorized, clinically useful, and safety-related work continues. Missing remains missing; it does not become normal, absent, negative, declined, or completed.

3.2 Care Plan carries accepted action, not every source act#

Care Plan receives applicable findings, person choices, professional contributions, and returned service outcomes. It creates or revises only the affected plan elements. It does not repeat the Assessment, reconcile medications, perform an external service, or convert a receiving owner's acceptance into the downstream result.

3.3 Ongoing is the longitudinal return engine#

Ongoing begins with the current Assessment baseline, current Care Plan, the person's priority, and exact open promises. It asks only about a relevant item, open result, due obligation, or credible change. Unasked domains remain not asked; they do not become “no change.”

Ongoing sends every meaningful completed, failed, corrected, or late downstream result to the affected owners. When the result materially changes an Assessment domain, it returns to the Assessment owner for bounded review while preserving the original as-of finding. When it changes an accepted plan action, it returns to the Care Plan owner. Ongoing does not silently rewrite either record.

A substantive inbound L2 interaction may replace redundant planned outreach only when it independently satisfies the Ongoing service requirement. An Assessment and Ongoing service may share one conversation only when both distinct results actually occur. Shared human time is counted once; closure remains separate.

3.4 Daily Proxi companion and caregiver pulse feed#

The Daily Companion is a Proxi product layer around the eight pillars, not a ninth pillar. It offers a configurable daily beneficiary interaction for approved information, action support, source-attributed self-report, and a request for a person. A permission-scoped Caregiver View shows only the latest source-dated confirmed picture, open actions, and explicit unknowns; it may ask the caregiver how they are holding up and whether they want practical help or a person now. Silence and missed interactions remain unknown.

The product episode proceeds in one no-repeat line:

1. verify the beneficiary or caregiver and current permission scope;
2. display the last confirmed source-dated picture and what remains unknown;
3. offer the beneficiary interaction without treating deferral, refusal, or silence as stability;
4. capture an optional caregiver pulse as caregiver-owned information;
5. prepare the relevant source-linked packet and stop candidates without deciding urgency or meaning;
6. route to the actual rostered performer—Philippine L1, Puerto Rico L2, the exact U.S. L3/L4 professional, specialist authority, or external endpoint—according to the act required;
7. let that person perform only the human or external act, without making the beneficiary or caregiver repeat the story; and
8. return one action plan with facts, owners, unknowns, expected result, and timing.

The episode may feed Ongoing, Caregiver Education/Support, Care Plan, Medication, Coordination, Referral/Services, Assessment, or 24/7 when their actual entry condition is met. The Daily Companion activity alone does not satisfy human navigator contact, 24/7 human first answer, caregiver assessment/support call, clinical assessment, service completion, or payment evidence. D-023 controls the product direction; O-061 controls activation details.

4. What a cross-pillar feed is#

A cross-pillar feed carries one source-linked obligation or limited context from one service owner to another. It is not an undifferentiated copied narrative and it is never automatic proof that the receiving service occurred.

Every candidate feed has one of three outcomes:

No downstream work opened is a disposition before a feed is created, not a fourth feed outcome. Not every completed finding or later observation creates receiving work. An actor or versioned deterministic rule authorized for the applicable nonclinical disposition may record no downstream work only when the fact is attributable and current enough for that limited conclusion, no local SOP requires a receiving act, no unresolved safety, clinical, permission, or authority question depends on it, the person has not requested follow-through, and no promise or plan action was created. Record the source-linked reason, any context destination, what remains unknown, and the event that would require renewed review. Protected clinical, safety, legal, or authority questions remain with the authorized human. This disposition does not erase the fact, create a second service, waive the annual Assessment, or prevent later bounded reassessment.

Software may nominate feeds. Deterministic approved rules may route known categories and required owners. The sending human verifies source-faithful content when human verification is required. The receiving owner accepts only the exact obligation within their authority.

5. Shared no-repeat packet#

The packet contains only what the receiving act needs, but it preserves enough context that the person is not forced to retell known facts.

For every feed, retain as applicable:

1. beneficiary identity and the person to whom the service/result belongs;
2. who reported, observed, authored, or produced each fact;
3. event/effective date and receipt date;
4. the person's exact words or the source's exact statement where material;
5. what is confirmed, reported, conflicting, stale, missing, corrected, late, or not asked;
6. what was already done, attempted, declined, failed, or promised, and by whom;
7. current urgency or safety disposition and the authorized person who made it;
8. current physical location and callback route when the next act may be clinical, urgent, or live;
9. participation, representative scope, caregiver involvement, disclosure, language, accessibility, and communication limits relevant to the next act;
10. the one requested downstream result or exact unresolved question;
11. the receiving owner, expected return condition, and known due timing without inventing an unsettled clock; and
12. the evidence that would truthfully complete the receiving work or establish a permitted non-success outcome.

The original source remains available. A summary does not replace it. Speaker identities remain separate. A caregiver statement does not become beneficiary agreement. A claim, directory, alert, model score, or copied record establishes only what its own source can establish.

Ask the person only for a missing current fact or choice that matters to the receiving act. Do not repeat an Assessment, medication history, caregiver assessment, referral intake, or service-choice conversation merely because ownership changed.

6. Preparation before judgment — D-021#

Preparation comes before the authorized human act:

1. Retrieve and source-link. Gather the smallest relevant set of current records, person statements, prior decisions, attempts, outcomes, conflicts, unknowns, and permission facts.
2. Preserve limits. Keep reported, observed, clinically interpreted, ordered, dispensed, authorized, accepted, and actually performed facts distinct.
3. Prepare the choice or question. Present bounded source-backed options and tradeoffs for a person choice, or form the exact question for the authorized professional.
4. Route to the least-cost permitted lane. Use the local SOP and D-017; do not add universal review.
5. Keep unaffected work moving. A protected answer blocks only the dependent act. Urgent or live-human service is never delayed for a perfect packet.

AI assistance stops or narrows when identity/authority is uncertain, the person requests human help, the issue is ambiguous or disputed, a protected question appears, or continued AI participation is not permitted. Refusal of AI does not equal refusal of GUIDE service.

7. Same-interaction evidence and count-once labor — D-016#

One conversation, preparation event, source pull, documentation event, handoff, or pursuit episode is recorded once. It may support several actual services, but only when each service's distinct content and result are independently evidenced.

7.1 Labor rules#

• Record the actual human performer, act, and active time once in the natural owning episode.
• Link that one labor record to every service whose distinct content/result it supported; do not copy the minutes.
• Record later separate L1 pursuit, L2 relationship work, L3/L4 protected work, supervisor recovery, release, external paid work, or follow-through once when it actually occurs.
• A task row's minute assumption is not automatically additive to every other row touched by the same event.
• Standing 24/7 coverage capacity is not added again as per-call labor when the authoritative 24/7 workload model already accounts for the relevant component.
• One service may receive zero incremental human minutes when its result is completed through an approved clean path. Zero human minutes does not mean the service result may be invented.

7.2 Service attribution rules#

• A mention, availability, packet, option, alert, task, handoff, acknowledgement, schedule, or attempt is not a furnished service.
• Each service attribution names the actual content, recipient/participant, performer or source, date, person response or real-world result, and remaining work.
• Contact evidence, GUIDE service evidence, and payment treatment remain separate. Program/compliance/billing applies the approved rule only after the real service record exists.

8. Receiving-owner acceptance is not downstream completion#

Receiving-owner acceptance means an identified authorized owner acknowledged the exact obligation and return condition. It transfers custody. It does not prove clinical disposition, external acceptance, service delivery, usefulness, or closure.

The following milestones must remain distinguishable when applicable; not every route requires every milestone:

The source pillar may complete its handoff after accepted custody if its local criteria allow. The receiving service remains open under its owner until its own objective result or permitted non-success endpoint. A sent message, internal assignment, queued task, voicemail, attempted transfer, or generic acknowledgement is not owner acceptance.

9. Standard cross-pillar handoff procedure#

1. Complete the immediate source-pillar obligation. The 24/7 responder answers; the assessor completes the applicable domain; the navigator furnishes the Ongoing result; the medication clinician performs the protected medication act; the referral owner pursues the chosen endpoint.
2. Separate urgent work from ordinary follow-through. Apparent emergency, clinical, safeguarding, or medication danger uses the approved immediate route. Routine education, referral, plan, or follow-up waits only where safety requires it.
3. Build the no-repeat packet. Reuse exact words, source facts, unknowns/conflicts, prior work, permission, current disposition, and one requested result.
4. Classify the feed. State whether another service occurred in the same interaction, downstream work opened, or the transfer is context only.
5. Ask only missing current facts or choices. Apply D-021; do not place L2 between a prepared clinical question and the authorized clinician.
6. When downstream work opens, obtain receiving-owner acceptance. Name the accepting owner and return condition. Wrong-owner or no-acceptance routes remain active failures. A same-interaction service already performed instead requires the correct performer, authority, content, and result evidence. A context-only update requires permitted delivery or availability evidence and opens no receiving service task or acceptance gate.
7. Perform the receiving service. The receiving pillar follows its own actors, source rules, steps, failures, minutes, and closure evidence.
8. Return the real result. Send material outcomes to Ongoing. Send accepted action consequences to Care Plan. If the result materially changes an Assessment domain, send it to the Assessment owner for bounded review while preserving history.
9. Communicate with the person. Provide the approved accessible result, unresolved status, next action, or changed promise when the owning SOP requires it.
10. Close each obligation truthfully. The source interaction may close while downstream work remains open. Do not use one pillar's closure to imply another's.

10. Pillar participation index#

Every pillar can receive from and send to each of the other seven when a real episode requires it. The fact that a route is possible does not mean a feed or service should be created.

10.1 High-level feed map#

This map is a reader's orientation. The exact task-bound matrix belongs in section 11.

11. Exact task-bound cross-pillar matrix#

11.1 Binding result and controlling rules#

Analysis 30 section 5 contains 31 compressed feed rows. This artifact binds all 31 rows to 48 receiving obligations. The expansion is limited to compound destinations and four necessary semantic splits: Assessment-to-Ongoing baseline receipt versus an accepted follow-up promise, plus three caregiver feeds that distinguish an actually furnished same-interaction CG26 service from separate later caregiver work. The matrix does not create a 359-by-359 workflow or change any source SOP.

The following rules control every row:

1. A source event, a receiving-owner acknowledgement, and a receiving service result are different facts. Acceptance closes transfer custody only.
2. same-interaction furnished is permitted only when the receiving pillar's distinct content, actor, and person-facing or real-world result actually occurred in the shared interaction.
3. One source event may support both same-interaction furnished and downstream episode opened only for different receiving acts. Record the completed act from its performer/content/result evidence and the later act from its receiving-owner acceptance; never require a new acceptance gate for the service already furnished and never let it complete the later service.
4. downstream episode opened means the named receiver accepted the source-linked packet and return condition. It carries no downstream completion credit.
5. context only means current information was delivered or made available through the permitted route for later use. It opens no receiving service task or human acceptance gate. An identified context owner handles access, conflict, correction, and supersession exceptions; availability, copying, or display is not a service.
6. One actual interaction, retrieval, explanation, handoff, or pursuit is entered once in the labor ledger. A second pillar adds labor only for genuinely additional work.
7. Clinical and medical acts never route to the Puerto Rico navigator operation. The beneficiary-location-authorized U.S. professional required for the act accepts and performs that work under D-015.
8. No row below settles O-003, O-004, O-009, O-010, O-019, O-024, O-026 through O-036, or the executed-Participation-Agreement questions. A return condition is a category, not a new SLA.

Return-condition phrases have their ordinary meaning: while connected for a live safety route; before the next dependent act; when the source-defined external, transition, or monitoring result returns; at the next natural person interaction unless a named safety or time-sensitive condition requires earlier action; or within the applicable initial, annual, or bounded-reassessment cycle without an invented clock.

11.2 Complete task-bound matrix#

Comprehensive Assessment source#

Person-Centered Care Plan source#

Ongoing Monitoring and Support source#

24/7 Access source#

Care Coordination source#

Referral and Services source#

Medication source#

Caregiver Education and Support source#

11.3 Mechanical coverage and reconciliation#

Analysis 30 section 5 source-row reconciliation#

Mechanical result: 31 of 31 compressed rows mapped; 0 omitted; 48 task-bound receiving rows — 40 downstream, four same-interaction, and four context-only; 0 invented task IDs. Compound rows expand only to their named destinations. Assessment-to-Ongoing and the three mixed caregiver feeds are split so context, actually furnished same-interaction service, and later downstream work never overwrite one another.

Eight-pillar inbound/outbound check#

Authoritative 359-task/card inventory reconciliation#

This matrix targets receiving work from the complete eight-pillar inventory; it does not imply that every task is a cross-pillar entry point.

Final semantic checks:

• Every receiving row names a real receiving task/card or exact stable source-manual title.
• Every row names the acceptor and the act that proves acceptance.
• Every row has a non-numeric return-condition category and one of the three permitted handoff statuses.
• Initial, annual, and bounded Assessment work remain Assessment; Ongoing uses baseline/delta without becoming recurring reassessment.
• 24/7 branches preserve human first answer and direct U.S. clinical/emergency acceptance without L1/L2 triage.
• Transition medication cannot close from ADT, a discharge list, an opened Medication case, or a clinician assignment.
• Referral receipt, intake, service start and usefulness remain separate stages.
• Same-call caregiver micro-education cannot complete the CG09 through CG18 full-training route; full training still requires the D-019 human application disposition.
• Task opening, packet delivery, acknowledgement, acceptance, scheduling, and a next owner are never represented as receiving-service completion.

12. Worked natural episode 1 — “My mother will not bathe” during a 24/7 call#

This episode demonstrates same-call service attribution, a possible bounded Assessment return, and a later Ongoing result without turning one call into eight completed services.

12.1 Live event and immediate route#

1. 24/7 human first answer. A Philippines human responder answers, establishes the safely obtainable identity, callback route, current location, caller relationship, and applicable communication/permission facts, and captures the caregiver's exact concern and timing.
2. Use current context carefully. The responder may see current communication needs, known caregiver participation, approved safety context, relevant Care Plan actions, and the last attributable function baseline. The responder does not present an old baseline as current truth.
3. Separate apparent danger or clinical uncertainty. Injury, acute change, severe agitation, pain, delirium-like change, abuse risk, skin concern, medication relationship, or uncertain clinical urgency invokes the approved beneficiary-location-authorized clinical/emergency route. L1/L2/AI does not decide that the event is safe or “just dementia.” Routine teaching waits only where the authorized disposition requires it.
4. Preserve unfinished work. A clinical connection does not erase the original caregiver support, function, plan, or service need.

12.2 Same-call content and feeds#

5. Possible same-call caregiver micro-service. When the proper clinical or safety disposition permits nonclinical guidance, a permitted L2 care-team member may furnish limited approved CG12 reinforcement during the connected episode, such as timing, privacy, a one-step invitation, environment, choice, stopping escalation, and how to seek help. The caregiver identifies one action to try. This is caregiver education/support only when the permitted human actually furnished the approved content and the caregiver response/action was recorded.
6. Full caregiver service remains distinct. Repeated difficulty, a need for practice/adaptation, or content beyond the short lesson opens full training or one-to-one support. Scheduling, sending material, or enrolling the caregiver does not complete that service. Under D-019, approved software/AI may carry the learning sequence, but the required human-owned application route remains as settled and O-036 remains open.
7. Care Plan feed. If the beneficiary/caregiver accepts a recurring approach or the current plan no longer fits, send the exact strategy, source, participants, owner, and expected result to Care Plan. A copied call note is context until actual beneficiary-led plan work occurs.
8. Referral feed. If the barrier is home help, equipment, accessibility, personal-care assistance, or caregiver capacity, send the current need/result, constraints, prior attempts, and person choice to Referral/Services. A candidate list is not a completed connection.
9. Medication/clinical feed. If the change follows a medication event or raises a treatment question, send source-separated facts and the exact question to the authorized clinician/Medication owner. Do not recommend a medication action.
10. Bounded Assessment feed. If the report credibly indicates a material ADL, cognition, behavior, pain, safety, home-context, or caregiver-status change, the Assessment owner accepts only the affected domain question. The original Assessment remains intact as an as-of record. The event does not automatically reopen all 49 cards.
11. Ongoing return. Ongoing receives the agreed action, the exact result to observe, and the next natural opportunity to ask whether it was tried and what happened. Do not create a separate quality-only call unless timing, safety, an actual promise, or person need warrants one.

12.3 Truthful evidence and labor#

• 24/7 result: live human answer, source-faithful concern capture, proper immediate route, and required information sharing.
• Possible caregiver result: approved content actually furnished plus the caregiver's stated intended action/help route.
• Opened but not completed: full training, clinical/Medication work, referral, Care Plan change, bounded Assessment, and later Ongoing follow-up unless each actually occurred.
• Count once: the shared call, capture, and documentation are one human episode. Credit multiple services only for their actual content/results. Later trainer, navigator, clinician, referral, Assessment, and follow-through labor is recorded once when performed.

13. Worked natural episode 2 — post-discharge medication confusion#

This episode demonstrates source-native medication evidence, transition coordination, direct protected routing, and the difference between an original call and the later service results.

13.1 Trigger and immediate safety#

1. A 24/7 call, Ongoing interaction, facility message, or permitted event feed indicates a recent discharge and conflicting medication information.
2. The first human captures the person's exact question, what they report taking or not taking, current location, callback route, symptoms/events, relevant caregiver statements, and actions already taken. Reported use remains reported use.
3. Apparent overdose, wrong-dose danger, serious symptom, fall, confusion, allergic-type reaction, or urgent advice request uses the approved direct clinical/emergency route before routine record completion. A prepared packet never delays urgent connection.

13.2 Distinct pillar work#

4. Care Coordination identifies the transition, obtains the discharge record and instructions, pending tests, follow-up appointments, equipment/home-service orders, responsible clinicians, and unresolved outside responses. An event notice is not a discharge summary; a request sent is not a returned result.
5. Medication Management preserves discharge, EHR, pharmacy, bottle/packaging, facility, claim, and person/caregiver reports as separate source assertions. It forms one exact discrepancy packet for the prescribing-authority or other approved clinician under the medication SOP.
6. Authorized clinician performs the protected reconciliation or decision and records complete-no-change, complete-with-change, or truthful incomplete status as permitted. Order, transmission, pharmacy response, dispense, possession, reported use, administration, cancellation, old supply, and monitoring remain separate.
7. Pharmacy/access work pursues the exact technical or practical barrier. Pharmacy acceptance or a paid claim does not prove the beneficiary obtained or used the medicine.
8. Caregiver Education/Support explains only the current source-authorized instruction and records the caregiver's intended use/application. A new clinical question returns directly to the authorized clinician.
9. Referral/Services handles chosen transport, food, home help, equipment, or other community support through the promised endpoint.
10. Care Plan receives only the attributable authorized medication result, current actions/owners, transition consequences, and remaining dependencies; it does not convert the earlier call note into regimen truth.
11. Ongoing follows the specific access/use, symptom, monitoring, appointment, equipment, and transition promises in the next appropriate interaction. It does not repeat reconciliation.
12. Assessment receives a material returned result as a bounded update/reassessment candidate for the affected medication, function, fall, cognition, transition, caregiver, or provider/service domain. The original Assessment finding remains traceable; the annual Assessment remains separately due.

13.3 Truthful evidence and labor#

• The original call or alert may complete only its own 24/7/Ongoing source obligation.
• Care Coordination requires its actual returned transition/provider result or truthful unresolved outcome.
• Medication requires the authorized result and then separately tracked execution/monitoring work.
• Caregiver Education requires actual source-faithful teaching/application content.
• Referral requires its promised real-world milestone.
• Care Plan and Assessment require their own review acts; context receipt alone is not service.
• Ongoing requires a real human continuity/result interaction when the follow-up occurs.
• Shared intake and source gathering are counted once; distinct later human/protected/external acts are counted once each.

14. Worked natural episode 3 — caregiver exhaustion or possible breakdown#

This episode demonstrates caregiver-owned information, immediate-risk separation, one-to-one support, referral, no-caregiver consequences, and the Assessment/Ongoing return.

14.1 Source and immediate disposition#

1. Comprehensive Assessment, Ongoing, Caregiver Education/Support, Care Plan work, or a 24/7 call captures the caregiver's exact words, current role/willingness, beneficiary participation/permission facts, location when relevant, recent events, prior supports, and immediate safety context.
2. Self-harm, abuse/neglect, abandonment, immediate medical danger, unsafe restraint, or another protected concern uses the approved emergency/clinical/safeguarding route. A burden score, sentiment signal, model label, or caregiver statement alone does not establish a diagnosis or disposition.
3. The authorized disposition and the original support need remain separate. A successful urgent handoff does not automatically close the caregiver's ongoing support need.

14.2 Distinct pillar work#

4. Same-interaction caregiver support. A permitted care-team member may furnish a substantive one-to-one support conversation: listening, approved problem-solving/coping support, clarification of available help, and one chosen next action. This is a caregiver-service result only when the human support content and caregiver response are recorded.
5. Caregiver education. A relevant bounded lesson/application touchpoint may be furnished now or a fuller service may be opened. Same-call support and education are credited separately only when each distinct content/result occurred; the shared minutes are counted once.
6. Referral/Services. The caregiver may choose a support group, counseling, legal/community resource, transport, in-home support, or other service. Referral pursues the exact promised endpoint; a list or appointment is not service start.
7. Care Plan. Beneficiary-led review carries any accepted caregiver-dependent action, backup, boundary, or contingency. Caregiver-owned sensitive information does not automatically enter beneficiary-facing or provider-shared content.
8. Ongoing. The longitudinal return records the chosen support/action and later attributable result without a generic extra contact. If the caregiver becomes unwilling/unavailable, Ongoing updates the current participation route and sends the material change to Assessment/Care Plan.
9. Bounded Assessment. A material change in caregiver identity, ability, willingness, knowledge, well-being, beneficiary function, or no-caregiver status reopens only the affected caregiver/function/safeguard domains. A caregiver-service conversation is not the caregiver Assessment itself.
10. 24/7 context. Only the approved current contact, accessibility, safety, and contingency information needed for future response is made available. Context availability is not a new 24/7 event.

14.3 Truthful evidence and labor#

• The caregiver's own service need, choice, and result stay caregiver-attributed.
• Human one-to-one support, education/application, clinical/safeguarding response, referral, Care Plan work, Ongoing work, and bounded Assessment each retain separate service evidence.
• The shared source conversation and documentation are counted once. Later service and professional acts receive their own actual minutes once.
• If no current caregiver remains after reasonable effort, caregiver services stop where inapplicable and the identified beneficiary support/safeguard needs transfer to accepted owners. Owner acceptance is not the actual safeguard result.

15. Shared closure review#

The shared review is a plain-language reconciliation surface. It does not replace any pillar's closure rule and it does not create one all-or-nothing service outcome.

For each natural episode, show:

1. What happened and what matters now. Exact source event, person words, dates, current location when relevant, and known limits.
2. Immediate source-pillar obligation. What the originating pillar actually completed and what it did not.
3. Same-interaction services. Which distinct service content/results actually occurred in the original interaction.
4. Context-only updates. Which pillars received information only.
5. Opened downstream work. Each exact obligation, receiving owner, acceptance status, return condition, and current first action.
6. Actual downstream results. What was furnished, decided, returned, failed, declined, or remained unresolved under the receiving SOP.
7. Person communication. What the beneficiary/caregiver was told, what they chose, what they expect next, and any accessibility/permission limits.
8. Assessment effect. No Assessment work opened, with the source-linked reason and re-entry condition retained; context correction; bounded affected-domain review; or independent initial/annual work still due.
9. Care Plan effect. No plan work, context only, focused review/revision, or reviewed-no-change result.
10. Ongoing return. Exact result/watch item/promise and the next natural or time-sensitive follow-up.
11. Labor reconciliation. Each human act and active minutes once, with links to every evidenced service it supported.
12. Corrections and late evidence. Original and corrected facts, affected prior recipients/results, reopened work, and completed correction communication.

15.1 Shared-episode status language#

Use precise language rather than a single ambiguous “closed” flag:

• source interaction complete/incomplete;
• context delivered/not delivered;
• receiving owner accepted/not accepted/wrong owner;
• receiving first action performed/not performed;
• service result furnished/incomplete/declined/truthful non-success/open;
• result returned/not returned;
• person informed/not informed/not currently reachable under the approved attempt policy;
• Assessment effect complete/open/not applicable;
• Care Plan effect complete/open/context only/not applicable;
• Ongoing return complete/open/not yet due/not applicable; and
• correction complete/open/not applicable.

A shared episode is reconciled only when every promised substep has a truthful disposition. Retry exhaustion, no response, technical restoration, internal assignment, or a generic external promise is not automatically resolution. A permitted non-success endpoint must come from the owning SOP and approved decision, not from this manual.

16. Failure, correction, and no-drop behavior#

17. Person burden and value before billing — D-020#

Before proactive person-facing work, the owner must be able to state:

1. why conversation is appropriate now;
2. which real GUIDE service will be furnished;
3. what useful beneficiary/caregiver result is expected;
4. why the person's participation is needed rather than backstage work; and
5. whether a recent or naturally occurring interaction already satisfies the purpose without redundant outreach.

Cadence creates a duty to furnish a genuine Ongoing human service, not permission to invent content. A stable required Ongoing contact begins with the person's priority and current Assessment/Care Plan baseline, addresses a relevant goal/action/question or chosen topic, and leaves an attributable result or help route. It does not need to repeat every screen. Domains not discussed remain not asked.

One primary navigator bundles applicable work where doing so helps the person. A substantive inbound qualifying interaction may replace redundant planned outreach only after its own actor, participant, purpose, content, result, documentation, and applicable timing are established. L1 or AI intake alone is not the qualifying human navigator service.

If no contact is due and no person-specific service exists, an empty billing month does not justify outreach, Assessment, medication reconciliation, Care Plan revision, clinical review, caregiver education, referral, or a manufactured downstream task. Payment treatment remains downstream of care semantics under the approved program/compliance process.

18. Settled cross-cutting decisions applied by this manual#

This manual does not reopen these settled principles:

19. Open-decision posture#

This manual provides semantic continuity only. It must not settle actor, timing, release, source-access, service/payment, or clinical policy that remains open.

Where the exact owner, source, timing, release actor, endpoint, or permitted non-success outcome is unresolved, link the open decision and keep the work visibly provisional. Do not guess the missing policy into local prose.

20. Semantic acceptance tests#

These are human-readable integration tests. The owning rule/test layer assigns any stable test IDs after owner approval.

21. Source and approval posture#

• Apply controlling law, current CMS requirements, and the executed GUIDE Participation Agreement first.
• Apply 01_Architecture_and_Control_Principles.md, settled decision-log entries, 02_Roles_and_Escalation.md, and the applicable pillar SOP in the project source order.
• Use primary current sources for any regulatory, clinical, interoperability, prescribing, privacy, or external-program claim added during review.
• Label sourced requirements, Proxi design, owner decisions, inferences, and recommendations separately.
• Do not describe the high-level feed map, task-bound matrix, work surfaces, or automated preparation as functionality already deployed.
• Treat every SOP and this integration manual as draft until the named clinical, compliance, privacy, operational, and program owners approve it.

22. Coverage and insertion verification#

This manual coordinates but does not alter the authoritative task denominator:

Before owner approval and field use:

1. confirm that section 11 contains the owner-adjudicated task-bound feed matrix;
2. mechanically confirm all 359 exact rows, task names, and order;
3. confirm that triggered numeric minute assumptions were not recalibrated; a stated zero-human clean path reflects the conditional D-021 route, not a new field estimate;
4. confirm that every feed preserves the local actor/source/closure rule;
5. confirm that Assessment is named everywhere as initial, annual, and bounded reassessment rather than only initial;
6. confirm that Ongoing is the longitudinal return engine and not a generic repeat Assessment;
7. confirm that each of the three worked episodes keeps owner acceptance separate from actual downstream result;
8. confirm that shared human work is counted once without under-crediting real distinct services; and
9. confirm that no open decision was settled through integration prose.

This manual is a canonical project draft, not an approved field SOP. It remains subject to the open decisions and named owner approvals above.