Enhanced dementia care | Proxi GUIDE Manual

These are evidence-backed candidate services beyond the public GUIDE minimum. They are not represented as CMS GUIDE requirements. The purpose of this file is to describe the literal work, the useful Proxi contribution, and the person who retains each human or clinical responsibility.

Some steps resemble work that GUIDE already requires at a defined occasion, such as fall-risk assessment during the comprehensive assessment, medication reconciliation, caregiver training, or transition support. In this file, the row means the additional frequency, depth, personalization, or closed-loop follow-through supplied by the enhanced service. The required baseline occurrence remains classified in its applicable eight-service SOP and is not being relabeled as optional.

Longitudinal caregiver coaching#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
LC01. Offer recurring coaching	Explain that the caregiver may return for practical coaching as situations change; ask whether they want coaching and how they prefer to participate.	NICE §1.11 recommends tailored support from diagnosis and as needed; WHO iSupport provides selectable caregiver lessons.	Partial. Proxi can present the service, accessible formats, and appointment choices and record the caregiver's preference.	Yes	Caregiver chooses; dementia-trained care navigator or educator answers questions.
LC02. Choose the immediate coaching goal	Ask the caregiver which current situation they most want help with and define a concrete result for the session.	NICE recommends support tailored to caregiver needs, preferences, and intended results; WHO iSupport lets caregivers choose relevant lessons.	Partial. Proxi can prompt for the situation and draft a goal for confirmation.	Yes	Caregiver and dementia-trained navigator or educator.
LC03. Understand what happens now	Ask what occurs before, during, and after the situation; what the caregiver has tried; what helped; and what made it harder.	NICE recommends personalized strategies and skills for responding to behavior and adapting communication.	Partial. Proxi can guide structured description, preserve the caregiver's words, and surface symptom or safety language.	Yes	Caregiver; navigator or educator; clinician if a new symptom or safety concern appears.
LC04. Select an approved coaching lesson	Match the stated goal to approved education on communication, everyday care, self-care, or behavior response without inventing individualized medical advice.	WHO iSupport covers dementia, caregiving, self-care, everyday care, and behavior changes; NICE recommends the same practical domains.	Partial. Proxi can retrieve the relevant approved lesson and exercises; the educator confirms fit.	Yes	Dementia-trained care navigator or educator.
LC05. Practice the skill	Rehearse the words, sequence, environmental change, or caregiver response using a realistic scenario and repeat until the caregiver can use it.	WHO iSupport uses examples, exercises, and feedback; NICE recommends building caregiver skills and adapting communication.	Partial. Proxi can generate an approved practice scenario, play the other role, and record questions; a human coach observes and corrects.	Yes	Caregiver and dementia-trained navigator or educator.
LC06. Agree on one home action	Choose a small action to try, when to try it, what support is needed, and what would count as useful or unhelpful.	NICE emphasizes personalized strategies and support designed around what the caregiver wants to achieve.	Partial. Proxi can draft the action recap, reminders, and plain-language instructions.	Yes	Caregiver chooses; navigator or educator confirms the action stays within approved coaching scope.
LC07. Check what happened	Contact the caregiver after the agreed interval; ask whether the action was tried, what happened, and what remains difficult.	Longitudinal follow-through implements NICE's “as needed after diagnosis” support and WHO's feedback-based exercises.	Partial. Proxi can schedule the check-in, bring forward the agreed action, and summarize the caregiver's report.	Yes	Caregiver and navigator or educator.
LC08. Adapt, continue, or escalate	Reinforce what worked, select another approved strategy when it did not, or connect new symptoms, danger, treatment questions, or caregiver mental-health concerns to the appropriate professional.	NICE supports tailored ongoing coaching and clinical response to distress; WHO iSupport is adaptable to changing caregiver needs.	Partial. Proxi can suggest the next approved lesson and identify configured escalation cues; it cannot decide clinical severity.	Yes	Navigator or educator; licensed clinician or behavioral-health professional when triggered.

Behavior and distress prevention#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
BD01. Receive the behavior or distress concern	Let the beneficiary or caregiver describe what is happening now and immediately connect apparent danger or severe distress to human help.	NICE §§1.7.1–1.7.3 calls for cause assessment before treatment and limits antipsychotic use to severe distress or risk.	Partial. Proxi can capture the report and surface configured danger cues, but cannot decide severity or disposition.	Yes	Beneficiary or caregiver; trained human responder; clinician or emergency service when triggered.
BD02. Describe the behavior observably	Record what the person did or said, when it started, how long it lasted, and its impact without labeling motive or diagnosis.	NICE recommends a structured assessment that explores reasons for distress rather than assuming a psychiatric cause.	Partial. Proxi can prompt for observable facts, timing, and source and keep inference separate.	Yes	Beneficiary or caregiver reports; navigator or trained dementia staff confirms the description.
BD03. Identify pattern and context	Ask what happened before and after, where it occurs, who is present, what needs may be unmet, and whether it is new or different from baseline.	NICE recommends checking clinical and environmental causes and using personalized psychosocial and environmental interventions.	Partial. Proxi can organize antecedents, consequences, routines, and repeated patterns.	Yes	Navigator or dementia-trained staff; clinician reviews a sudden or clinically concerning change.
BD04. Assess possible medical causes	Evaluate pain, delirium, infection, medication effects, sleep disruption, or other medical contributors when the report or pattern warrants it.	NICE §1.7.1 specifically names pain and delirium among causes to check and address before treatment.	No. Proxi may prepare observations and records but cannot perform the clinical assessment.	Yes	Licensed clinician acting within scope; pharmacist when medication contribution is assessed.
BD05. Assess unmet needs and environmental contributors	Consider communication difficulty, hunger, toileting, boredom, overstimulation, loneliness, unfamiliar people, inappropriate care, or environmental barriers.	NICE recommends exploration of reasons for distress and psychosocial and environmental intervention as initial and ongoing management.	Partial. Proxi can guide an approved needs and environment review and summarize modifiable factors.	Yes	Dementia-trained navigator, nurse, social worker, occupational therapist, or other qualified team member.
BD06. Determine urgency and treatment	Decide whether the person needs emergency care, urgent clinical review, treatment of a cause, medication review, or routine non-drug support.	NICE makes risk, severe distress, cause treatment, and medication use clinical decisions.	No. Proxi cannot determine medical urgency, diagnosis, or treatment.	Yes	Licensed clinician; emergency or safeguarding authority when indicated.
BD07. Build the non-drug response plan	Select person-specific communication, routine, activity, sensory, or environmental strategies and state when to stop and seek help.	NICE recommends psychosocial/environmental interventions and personalized activities for agitation or aggression.	Partial. Proxi can assemble options from an approved library and draft the plan after qualified selection.	Yes	Dementia-trained clinician, therapist, nurse, social worker, or educator according to the intervention.
BD08. Coach the people who will use the plan	Explain and rehearse the agreed response with the caregiver and other involved people; confirm they understand what is and is not authorized.	NICE recommends caregiver training in understanding and responding to behavior and adapting communication.	Partial. Proxi can render approved instructions, practice scenarios, and reminders.	Yes	Dementia-trained navigator or educator; caregiver and other authorized support people.
BD09. Review outcomes and revise	Ask whether distress, frequency, duration, safety, or caregiver burden changed; obtain clinical review for worsening or new features; revise the human plan.	NICE describes psychosocial/environmental support as ongoing and requires reassessment of medication used for distress.	Partial. Proxi can schedule follow-up, compare reported observations, and prepare the review.	Yes	Navigator or educator; licensed clinician for worsening symptoms, treatment, or medication review.

Fall-prevention service#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
FL01. Ask about falls and instability	Ask about falls, near-falls, unsteadiness, fear of falling, and injuries since the last review.	CDC STEADI uses screening to identify older adults needing fall-risk assessment.	Partial. Proxi can administer approved questions, collect dates and circumstances, and flag positive answers.	Yes	Beneficiary or caregiver reports; trained staff administers or confirms; clinician reviews positives.
FL02. Respond to a fall that may need immediate care	Obtain the current location and reported injury or symptoms and connect the person to qualified urgent assessment.	CDC STEADI distinguishes screening from clinical assessment and intervention; acute injury requires human clinical response.	Partial. Proxi can initiate the approved urgent route and pass reported facts but cannot judge injury severity.	Yes	Licensed clinician, urgent care, or emergency services according to the actual situation.
FL03. Perform the clinical fall-risk assessment	Assess gait, strength, balance, orthostatic symptoms, vision, feet, cognition, comorbidities, and other modifiable risks appropriate to the person.	CDC STEADI's clinical algorithm proceeds from screening to assessment of modifiable risk factors.	No. Proxi can assemble history and scores but cannot perform or interpret the clinical assessment.	Yes	Physician, advanced practice clinician, nurse, physical therapist, occupational therapist, or other qualified professional within scope.
FL04. Review the home and daily environment	Identify stairs, lighting, rugs, bathroom hazards, footwear, mobility-device issues, and routines that contribute to risk.	CDC STEADI includes home safety and modifiable environmental risk in coordinated fall prevention.	Partial. Proxi can guide an approved checklist and organize photographs or reports; a qualified person determines individualized safety changes.	Yes	Occupational therapist, trained home-safety professional, nurse, or clinician; beneficiary and caregiver participate.
FL05. Review medicines that may increase fall risk	Assess whether medicines or combinations may contribute to sedation, dizziness, hypotension, vision change, or impaired balance.	CDC STEADI-Rx uses pharmacist screening, medication review, provider communication, and response.	No. Proxi can assemble the reconciled list and reported symptoms but cannot determine medication risk or changes.	Yes	Pharmacist or prescribing clinician.
FL06. Select the fall-reduction interventions	Decide whether the person needs strength and balance work, PT or OT, vision care, medication action, mobility support, home changes, or another intervention.	CDC STEADI links assessed modifiable risks to individualized clinical and community interventions.	No. Proxi cannot choose clinical treatment or judge suitability.	Yes	Qualified clinician, physical therapist, occupational therapist, pharmacist, or eye-care professional as applicable.
FL07. Arrange the selected services and equipment	Schedule referrals, help obtain mobility or safety equipment, coordinate transportation, and resolve coverage or vendor barriers.	STEADI depends on completing the intervention, not screening alone; navigation makes the clinical plan usable.	Full where connected. Proxi can coordinate connected scheduling, reminders, approved referrals, and status follow-up; people handle exceptions and services.	Partial	Care navigator or coordinator for exceptions; external providers and vendors furnish the service.
FL08. Teach and implement the approved plan	Explain approved exercise, device, footwear, home-safety, and help-seeking instructions and confirm the person can use them.	CDC provides patient and caregiver fall-prevention resources and coordinated intervention guidance.	Partial. Proxi can deliver approved materials and reminders; hands-on training and individualized correction remain human.	Yes	PT, OT, nurse, navigator, caregiver, or equipment professional according to the plan.
FL09. Follow up after intervention or another fall	Confirm completion, ask about new falls or barriers, reassess when indicated, and update the prevention plan.	CDC's coordinated approach includes follow-up and reassessment of screening, assessment, and intervention.	Partial. Proxi can track completion and collect new reports; clinicians interpret change and revise treatment.	Yes	Care navigator; qualified clinician or therapist when reassessment is indicated.

Wandering and missing-person preparedness#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
WN01. Ask about wandering and getting-lost signs	Ask about leaving unexpectedly, getting lost on familiar routes, returning late, exit-seeking, pacing, or talking about former obligations.	NIA wandering guidance describes warning signs and recommends safeguards.	Partial. Proxi can administer approved questions and record incidents and sources.	Yes	Beneficiary or caregiver; navigator or trained dementia staff; clinician reviews a new change.
WN02. Act when the person is currently missing	Start the approved missing-person response immediately, share the current photograph and known destinations, and involve emergency responders without waiting for routine follow-up.	NIA recommends preparing identification, photographs, contacts, and safeguards so a missing person can be found safely.	Partial. Proxi can display the approved response plan, notify configured contacts, and assemble known facts; it cannot command emergency operations.	Yes	Caregiver or human responder; law enforcement, 911, or search-and-rescue authority.
WN03. Assess sudden change and individualized risk	Determine whether new wandering reflects delirium, illness, medication effects, unmet need, environmental change, or another clinical or safeguarding concern and decide the safe response.	NIA advises prevention tailored to the person's pattern; sudden or unsafe change requires professional assessment beyond education.	No. Proxi can prepare incident history but cannot determine cause, restrictions, or risk disposition.	Yes	Licensed clinician and safeguarding professional when applicable.
WN04. Map patterns, triggers, and likely destinations	Record when and where wandering occurs, preceding events, routines, former homes or workplaces, and places the person may seek.	NIA recommends knowing likely destinations and the local environment when preparing for wandering.	Partial. Proxi can organize incidents, times, routes, and recurring contextual factors.	Yes	Beneficiary when able; caregiver; navigator or trained dementia staff.
WN05. Build a prevention routine	Agree on supervision, daily check-ins, meaningful activity, transportation, rest, toileting, and other routines intended to reduce unsafe leaving while preserving mobility.	NIA recommends practical prevention while maintaining safety; personalized routines address common departure triggers.	Partial. Proxi can draft a routine from approved options and send reminders; qualified humans confirm individualized safety.	Yes	Beneficiary, caregiver, navigator, occupational therapist, or clinician according to risk.
WN06. Make the home safer	Select and implement appropriate door alerts, signs, locks, fencing, window limits, lighting, and safe indoor or outdoor movement areas without creating a new emergency hazard.	NIA recommends locks, signs, alarms, fencing, and other environmental safeguards.	Partial. Proxi can guide an approved checklist and help source products; a qualified person judges fit and emergency egress.	Yes	Caregiver; occupational therapist, home-safety professional, landlord, or contractor; clinician when restrictions are considered.
WN07. Arrange identification and location supports	Discuss ID jewelry or clothing labels, current contact information, GPS options, and safe-return programs; obtain the person's or authorized decision-maker's choice.	NIA recommends identification, medical bracelets, GPS, and safe-return options.	Partial. Proxi can present approved options, prepare enrollment, and remind people to update contact details.	Yes	Beneficiary or authorized decision-maker; caregiver and navigator support the choice.
WN08. Create the missing-person response plan	Keep a current photograph, description, emergency contacts, known destinations, neighborhood hazards, and instructions on whom to call and what to say.	NIA recommends a current photograph, notifying neighbors or police where appropriate, and advance preparation.	Partial. Proxi can assemble and update the plan and produce an accessible copy.	Yes	Beneficiary or authorized representative; caregiver; navigator; local emergency authority may advise.
WN09. Rehearse the plan	Walk the caregiver and other support people through a simulated incident, confirm access to the plan, and correct confusion before an emergency.	Preparedness makes NIA's recommended safeguards usable rather than merely documented.	Partial. Proxi can run an approved scenario and checklist; a human coach observes understanding.	Yes	Caregiver, authorized support people, and dementia-trained navigator or educator.
WN10. Review after an incident or meaningful change	Ask what occurred, whether the plan worked, what new risks appeared, and whether clinical reassessment or environmental change is needed.	NIA recommends safeguards based on the person's current wandering risk and situation.	Partial. Proxi can reconstruct the incident and track agreed changes; humans reassess risk and modify restrictions or treatment.	Yes	Navigator; licensed clinician, OT, or safeguarding professional when triggered.

Hearing and vision optimization#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
SV01. Ask about sensory function and devices	Ask about hearing or vision difficulty, recent assessments, glasses, hearing devices, batteries, fit, loss, nonuse, and communication problems.	NICE §§1.8.10–1.8.11 links dementia care to hearing assessment and regular eye care.	Partial. Proxi can administer approved questions and gather device and appointment history.	Yes	Beneficiary or caregiver; trained navigator; clinician reviews new sensory symptoms.
SV02. Verify prior recommendations and follow-up	Obtain available audiology, eye-care, and device recommendations and identify unfinished referrals or expired follow-up.	NICE recommends hearing assessment and an eye test soon after diagnosis and then every two years, with referral help when needed.	Full where connected. Proxi can retrieve connected records, request missing reports, and track due follow-up.	Partial	Care navigator or records staff when sources are not connected or facts conflict.
SV03. Perform sensory assessment and treatment	Assess hearing or vision, diagnose the cause, and prescribe or recommend clinical treatment or devices.	NICE assigns hearing and vision assessment to the relevant clinical services.	No. Proxi cannot diagnose sensory loss, prescribe a device, or determine treatment.	Yes	Audiologist, optometrist, ophthalmologist, physician, or other licensed professional within scope.
SV04. Arrange appointments and access	Schedule the selected assessment or follow-up, arrange transportation and accommodations, and resolve coverage, vendor, or language barriers.	NICE specifically recommends referral help for people who cannot organize appointments themselves.	Full where connected. Proxi can coordinate connected scheduling, reminders, transportation requests, and administrative follow-up.	Partial	Care navigator or coordinator for exceptions; sensory-care provider performs the service.
SV05. Obtain the prescribed device or correction	Help order, fit, collect, repair, or replace clinician-recommended glasses, hearing aids, assistive listening devices, or other supports.	Closing the device and access gap operationalizes NICE's sensory-care recommendations.	Partial. Proxi can track orders and vendors and send pickup or maintenance reminders; fitting and prescribing remain professional.	Yes	Audiologist, optician, eye-care professional, device vendor, beneficiary, and navigator as applicable.
SV06. Establish the daily device routine	Agree where devices are stored, who checks cleaning and charging or batteries, when they are worn, and what to do when they fail.	Practical device use is the value-add beyond documenting that assessment occurred.	Partial. Proxi can create routine prompts, maintenance reminders, and troubleshooting guidance approved by the provider.	Yes	Beneficiary; caregiver when involved; navigator; audiology or vision staff for device-specific problems.
SV07. Adapt all service communication	Use the person's preferred language, visual aids, captions, volume, lighting, large print, positioning, pace, and confirmation method in future contacts.	NICE recommends modified communication and accessible dementia services for people with sensory impairment.	Partial. Proxi can render accessible formats, captions, and reminders of preferences; the human communicator must use and verify them.	Yes	Every navigator, educator, clinician, or responder communicating with the person.
SV08. Check whether correction helped	Ask whether communication and daily function improved, whether the device is being used, and whether new difficulty or non-tolerance needs professional review.	NICE's sensory recommendations support ongoing access rather than a one-time recorded referral.	Partial. Proxi can schedule follow-up and compare reported barriers; it cannot interpret clinical response.	Yes	Navigator; audiologist or eye-care professional when reassessment is needed.

Personalized medication-use support after clinician approval#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
MU01. Confirm the approved regimen before support	Verify that a prescribing clinician has reconciled the current regimen and supplied the instructions that the support routine will implement; stop when instructions conflict.	AHRQ MATCH separates reconciliation from implementation; NICE medicines adherence supports informed, individualized use.	Partial. Proxi can compare source dates and instructions and flag conflict but cannot choose the correct regimen.	Yes	Clinician with prescribing authority resolves conflict; navigator confirms the support uses the approved result.
MU02. Ask how medicines are actually being used	Ask nonjudgmentally about missed, delayed, stopped, restarted, reduced, or extra doses and how use differs from the approved schedule.	NICE recommends routine, non-blaming adherence questions about actual medicine-taking behavior.	Partial. Proxi can administer the approved questions and preserve the beneficiary's or caregiver's report.	Yes	Beneficiary or caregiver; navigator or trained medication-support staff; clinician reviews discrepancies.
MU03. Identify the specific adherence barrier	Distinguish beliefs, concerns, side effects, memory, dexterity, vision, swallowing, cost, supply, packaging, transport, and routine problems.	NICE distinguishes intentional from practical non-adherence and recommends support targeted to the person's actual difficulty.	Partial. Proxi can structure the barrier interview and group reported issues without interpreting symptoms.	Yes	Beneficiary or caregiver; navigator; pharmacist or prescriber for side effects and clinical concerns.
MU04. Let the beneficiary choose feasible support	Present approved options such as reminders, logs, alternative packaging, delivery, pill organization, or assistance and ask what the beneficiary prefers.	NICE recommends asking what support the person prefers and tailoring intervention rather than applying one solution to everyone.	Partial. Proxi can match stated barriers to an approved option list and explain practical features.	Yes	Beneficiary or authorized decision-maker; caregiver when involved; navigator.
MU05. Obtain clinical decisions needed to simplify the routine	When the feasible routine would require a dose, timing, formulation, drug, or regimen change, have the prescriber or pharmacist assess and authorize it before implementation.	NICE reserves treatment changes for healthcare professionals and recommends shared decisions about risks, benefits, and side effects.	No. Proxi may prepare the barrier and options but cannot select or authorize a change.	Yes	Prescribing clinician; pharmacist within scope; beneficiary participates in the decision.
MU06. Resolve supply, packaging, and delivery barriers	Coordinate with the pharmacy, payer, prescriber, transport, or assistance program to obtain the approved medicine and selected support format.	NICE includes cost, supply, alternative packaging, and multicompartment systems among individualized adherence issues and supports.	Partial. Proxi can prepare requests, track status, and automate approved administrative follow-up.	Yes	Navigator or medication coordinator; pharmacy, payer, prescriber office, or assistance-program staff.
MU07. Set up the selected reminder or organization support	Configure digital reminders or logs, or arrange hands-on setup of boxes, packaging, calendars, or supervised administration according to the approved regimen.	NICE lists recording, monitoring, alternative packaging, and multicompartment systems as targeted practical interventions.	Partial. Proxi can configure supported digital tools and produce instructions; physical setup and verification may need a person.	Yes	Beneficiary, caregiver, navigator, pharmacist, facility staff, or home-care worker according to the support.
MU08. Teach back the approved schedule	Explain the clinician-approved schedule in accessible language and ask the beneficiary or caregiver to show or say how it will be followed.	NICE recommends individualized information, discussion rather than leaflet-only delivery, and checking understanding.	Partial. Proxi can render approved instructions and prompt teach-back; it cannot answer an unapproved clinical question.	Yes	Navigator or clinician using approved content; beneficiary and caregiver as applicable.
MU09. Monitor use and new concerns	Ask whether the routine was usable, medicines were obtained and taken as reported, and any symptom, refusal, or side-effect concern appeared.	NICE recommends agreed follow-up review and regular review of adherence, knowledge, concerns, and support needs.	Partial. Proxi can schedule follow-up, collect reports, and surface configured concern cues.	Yes	Beneficiary or caregiver; navigator; clinician for discrepancies, symptoms, refusal implications, or side effects.
MU10. Clinically respond and update the approved plan	Assess reported symptoms or discrepancies, decide whether treatment or support should change, and provide a new reconciled instruction when indicated.	AHRQ MATCH assigns reconciliation to a defined clinical process; NICE reserves treatment and side-effect decisions for healthcare professionals.	No. Proxi can prepare evidence and record the authorized result but cannot reconcile or change treatment.	Yes	Clinician with prescribing authority; pharmacist within scope; beneficiary participates.

High-touch recovery after care transitions#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
TR01. Detect the transition and reach the dyad	Identify admission, discharge, or move between settings; confirm where the person is now; and arrange an early human recovery contact.	AHRQ RED follow-up guidance uses early post-discharge contact; NICE §1.12.2 recommends review after every transition.	Partial. Proxi can detect connected events, collect location facts, and schedule outreach; a human handles uncertain events and the substantive contact.	Yes	Care navigator or transition coordinator; beneficiary or caregiver.
TR02. Obtain the discharge and transfer information	Gather the discharge summary, medication instructions, appointments, pending tests, equipment, home services, warning signs, and contact routes.	AHRQ RED reviews health, medicines, appointments, home services, and problem plans; NICE emphasizes transferable care information.	Full where connected. Proxi can retrieve, request, organize, and label available records and identify missing items.	Partial	Transition coordinator or records staff pursues inaccessible sources; clinicians resolve conflicting instructions.
TR03. Conduct the early recovery call	A human asks how the person is doing, what they understood, what they obtained, and what has not worked since the move.	AHRQ describes a clinical follow-up call as essential support between discharge and follow-up care.	Partial. Proxi can prepare questions, provide context, and draft notes but cannot replace the human recovery conversation.	Yes	Puerto Rico care navigator conducts the nonclinical recovery conversation with an immediate transfer route to the separate U.S. clinical workforce. Any clinical status review is performed by a separate beneficiary-location-authorized U.S. clinician and counted as clinical minutes, whether joined to the call or completed separately. Beneficiary and caregiver participate as applicable. Final navigator/clinical minute split remains `O-051`.
TR04. Check health status and warning signs	Ask about new or worsening symptoms, falls, confusion, intake, pain, function, and the warning signs listed in the discharge instructions.	AHRQ RED specifically includes health-status review and identification of misunderstandings or concerns.	Partial. Proxi can administer approved questions and surface concern cues but cannot interpret severity.	Yes	Puerto Rico navigator may ask only approved structured questions and record the person's answer source-faithfully. A separate beneficiary-location-authorized U.S. clinician reviews positive findings and owns every interpretation, urgency decision, and clinical conclusion. Final role/minute split remains `O-051`.
TR05. Determine the clinical response	Decide whether symptoms require emergency care, urgent evaluation, routine follow-up, testing, or another treatment action.	The AHRQ follow-up model uses clinical staff because symptom and discrepancy resolution requires clinical judgment.	No. Proxi cannot determine urgency, diagnosis, or treatment.	Yes	Licensed clinician or emergency professional.
TR06. Reconcile post-transition medicines	Compare pre-transition use, facility or hospital orders, discharge instructions, pharmacy supply, and current home use; resolve discrepancies before giving a final regimen.	AHRQ MATCH is specifically designed for medication reconciliation at transitions and handoffs.	No. Proxi can assemble and compare sources but cannot reconcile or authorize medication changes.	Yes	Clinician with prescribing authority; pharmacist within scope.
TR07. Verify appointments, equipment, and home services	Confirm dates, transportation, equipment delivery and usability, home-health or personal-care start, and who the person should call for problems.	AHRQ RED includes appointments, home services, and a plan for problems; closing these gaps makes recovery visible.	Full where connected. Proxi can verify connected status, send reminders, and request updates; people resolve exceptions and deliver services.	Partial	Care navigator or transition coordinator; provider, vendor, home-service, and transport staff.
TR08. Resolve practical and communication gaps	Correct missing instructions, inaccessible formats, pharmacy or equipment delays, absent transportation, unavailable caregivers, and failed service handoffs.	AHRQ RED is designed to identify and address discharge-plan discrepancies and misunderstandings.	Partial. Proxi can identify gaps, draft requests, and track resolution; humans make service decisions and address sensitive barriers.	Yes	Care navigator or transition coordinator; appropriate provider, pharmacy, vendor, or community service.
TR09. Review needs, wishes, and plans after the transition	Ask whether goals, preferences, caregiver capacity, residence, and support needs changed and update the appropriate human-owned plans and contacts.	NICE §1.12.2 recommends reviewing needs, wishes, care plans, and advance plans after every transition.	Partial. Proxi can prompt the review and draft factual updates; beneficiary choice and clinical plan changes remain human.	Yes	Beneficiary; caregiver as chosen; care navigator; clinician for clinical plan changes.
TR10. Continue recovery follow-up until the handoff works	Recontact the dyad on unresolved medicines, appointments, equipment, services, symptoms, or understanding and keep the responsible human involved until the gap is resolved or a new plan is agreed.	AHRQ RED treats the call as support through the first follow-up and requires appropriate post-call actions.	Partial. Proxi can maintain the follow-up list, reminders, and summaries; humans resolve needs and make clinical decisions.	Yes	Care navigator or transition coordinator; clinician and external service owners as triggered.

Early and recurring future planning#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
FP01. Offer planning without pressure	Explain the purpose of planning ahead, ask whether the beneficiary wants to discuss it now, and respect a decision to wait or limit the discussion.	NICE §§1.1.12–1.1.13 recommends early, ongoing opportunities and later review, not forced completion.	Partial. Proxi can present approved plain-language information and record readiness and preferred participants.	Yes	Beneficiary; care navigator or trained planning facilitator.
FP02. Elicit goals, values, and future preferences	Ask what matters most, what situations the beneficiary wants to prepare for, and what values should guide future care and daily life.	NICE recommends advance statements of wishes, preferences, beliefs, and values.	Partial. Proxi can guide and summarize the beneficiary's own words without deciding what they should value.	Yes	Beneficiary; chosen supporters; trained facilitator.
FP03. Identify trusted decision supporters	Ask whom the beneficiary wants involved, what information may be shared, and whom they may wish to appoint for future decisions.	NICE recommends discussion of future decision authority and advance planning while the person can participate.	Partial. Proxi can explain role categories from approved material and capture names and permissions.	Yes	Beneficiary chooses; navigator facilitates; attorney advises on legal authority.
FP04. Explain planning options and documents	Provide approved education about advance statements, advance directives, healthcare agents, financial and long-term-care planning, and where professional advice is needed.	NICE lists advance statements, powers of attorney, and treatment decisions as recurring planning topics.	Partial. Proxi can deliver jurisdiction-approved education and check understanding; it cannot provide legal or clinical advice.	Yes	Trained navigator; attorney, financial professional, or clinician for advice within their scope.
FP05. Arrange professional planning conversations	Connect the beneficiary to the clinician, attorney, financial counselor, social worker, or other professional needed for the chosen planning work.	NICE supports ongoing opportunities to plan and involvement of relevant professionals.	Full where connected. Proxi can coordinate selected referrals, appointments, reminders, and document requests.	Partial	Care navigator handles exceptions; licensed or credentialed professional provides advice.
FP06. Complete clinical counseling and medical orders	Discuss prognosis and treatment implications when requested, determine capacity when clinically relevant, and complete any clinician-owned directive, POLST, or medical order.	NICE separates advance discussions from treatment decisions and best-interest or capacity-dependent clinical work.	No. Proxi cannot determine capacity, provide individualized medical counseling, or create medical orders.	Yes	Physician, advanced practice clinician, or other authorized professional within state law and scope.
FP07. Organize and share completed documents	Help the beneficiary store copies, identify who should receive them, obtain permission, and place them with the appropriate providers and trusted people.	Advance planning has practical value only when authorized decision-makers and care settings can find the current documents.	Partial. Proxi can inventory documents, prepare permitted distribution, and remind the beneficiary about missing destinations.	Yes	Beneficiary or authorized representative controls sharing; navigator or records staff assists.
FP08. Revisit the plan after change and at agreed intervals	Ask whether wishes, chosen supporters, health, residence, or documents changed; connect needed revisions to the responsible professional.	NICE recommends offering review and change of advance statements and decisions at each care review.	Partial. Proxi can schedule the review, display current choices, and draft change requests; humans make and authorize revisions.	Yes	Beneficiary; navigator; clinician, attorney, or other professional according to the revision.

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
MS01. Learn the person's interests and identity	Ask about meaningful roles, culture, faith, music, hobbies, relationships, routines, dislikes, and activities the person wants to retain or revisit.	NICE §§1.4.1–1.4.3 recommends activities tailored to preferences plus appropriate cognitive stimulation or reminiscence.	Partial. Proxi can guide a life-history and preference conversation and organize the person's own words.	Yes	Beneficiary; caregiver or family when chosen; navigator or activity specialist.
MS02. Understand current connection and barriers	Ask whom the person sees, whether they feel lonely, what participation has stopped, and whether transport, cost, hearing, vision, mobility, fear, or caregiver availability is blocking it.	NICE links accessible services and preference-based wellbeing activities; identifying barriers makes connection practical.	Partial. Proxi can administer approved questions and organize barriers; mental-health or safety concerns trigger clinical review.	Yes	Beneficiary or caregiver; navigator; clinician or behavioral-health professional when triggered.
MS03. Assess clinical or therapeutic suitability when needed	Determine whether an activity requires adaptation because of falls, wandering, seizures, cardiopulmonary limits, behavioral distress, or a rehabilitation goal.	NICE assigns cognitive stimulation, reminiscence, and rehabilitation interventions to appropriately qualified delivery.	No. Proxi can prepare preferences and reported risks but cannot judge clinical suitability.	Yes	Licensed clinician, occupational therapist, physical therapist, psychologist, or qualified therapy professional as applicable.
MS04. Build a small, personalized activity plan	Choose realistic daily or weekly activities, social contacts, needed assistance, and a way to notice enjoyment or frustration.	NICE recommends a range of wellbeing activities tailored to the person's preferences.	Partial. Proxi can suggest approved options and draft a schedule; the beneficiary chooses and qualified humans confirm safety.	Yes	Beneficiary; caregiver when involved; navigator or activity specialist; clinician on trigger.
MS05. Connect to suitable people and programs	Identify and arrange community, faith, volunteer, arts, recreation, cognitive-stimulation, reminiscence, or social groups that fit preferences and ability.	NICE recommends cognitive stimulation and considers group reminiscence for appropriate people with mild to moderate dementia.	Partial. Proxi can search approved resources, compare logistics, register, and send reminders.	Yes	Beneficiary chooses; navigator coordinates; trained facilitator or therapist delivers structured programs.
MS06. Remove practical participation barriers	Arrange transportation, accompaniment, accessible format, hearing or vision support, cost assistance, timing changes, or an at-home alternative.	NICE recommends accessible services for transport, sensory, physical, and caregiver constraints.	Full where connected. Proxi can coordinate approved logistical supports and track them; people resolve exceptions and provide accompaniment.	Partial	Care navigator, community organization, transport provider, caregiver, or direct support worker.
MS07. Check actual participation and experience	Ask whether the person attended or engaged, enjoyed it, felt distressed or fatigued, and wants to continue, change, or stop.	Preference-tailored wellbeing requires feedback from the person rather than attendance alone.	Partial. Proxi can collect feedback and compare participation with the agreed plan; it cannot interpret clinical change.	Yes	Beneficiary; caregiver when chosen; navigator or activity specialist.
MS08. Adapt or clinically reassess the activity plan	Change the routine when preferences or function change and obtain professional review when distress, safety, or rehabilitation needs emerge.	NICE describes personalized activities and qualified cognitive or functional interventions rather than fixed generic programming.	Partial. Proxi can suggest alternatives and route concern cues; humans decide clinical suitability and the revised plan.	Yes	Navigator or activity specialist; licensed clinician or therapist on trigger.

Functional independence and reablement#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
FI01. Choose a beneficiary-defined functional goal	Ask which everyday task the person wants to keep or regain and what successful participation would look like.	NICE §1.4.4 defines cognitive rehabilitation around personally relevant functional goals and strengths.	Partial. Proxi can prompt examples and capture the beneficiary's goal without choosing it.	Yes	Beneficiary; caregiver when chosen; navigator or therapist facilitates.
FI02. Describe current performance and context	Record how the task is done now, assistance used, errors, frustration, environment, timing, and what has already helped.	NICE cognitive rehabilitation builds from functioning, strengths, and ways to compensate for impairment.	Partial. Proxi can guide a structured report and organize observations; it cannot clinically assess function.	Yes	Beneficiary or caregiver; navigator; therapist reviews the report.
FI03. Perform the functional assessment	Evaluate cognition, motor ability, sensation, environment, safety, and task demands relevant to the chosen goal.	NICE recommends occupational therapy or cognitive rehabilitation to support functional ability.	No. Proxi cannot perform or interpret the licensed functional assessment.	Yes	Occupational therapist or other qualified rehabilitation clinician.
FI04. Create the rehabilitation or reablement plan	Select compensatory techniques, task simplification, cues, assistive devices, environmental changes, practice schedule, and safety limits.	NICE defines cognitive rehabilitation as working toward functional goals using strengths and compensation.	No. Proxi can prepare options and draft the authorized plan but cannot design therapy independently.	Yes	Occupational therapist or qualified cognitive-rehabilitation professional; beneficiary participates.
FI05. Arrange therapy, devices, and environmental support	Schedule services, obtain recommended devices, coordinate home modifications, and solve transport, coverage, or vendor problems.	Completing the recommended support makes the functional intervention usable at home.	Full where connected. Proxi can coordinate referrals, orders, reminders, and status tracking; humans handle exceptions and installation.	Partial	Navigator; therapist; equipment vendor, contractor, payer, or transport provider.
FI06. Teach the approved strategy	Demonstrate the cues, sequence, device, or environmental setup and have the beneficiary and caregiver practice it safely.	Cognitive rehabilitation works through guided practice toward the person's functional goal.	Partial. Proxi can supply approved prompts and practice reminders; a qualified human demonstrates and corrects.	Yes	Occupational therapist or rehabilitation professional; beneficiary and caregiver as applicable.
FI07. Support practice and remove barriers	Maintain the agreed practice routine, answer nonclinical setup questions, replace missing supports, and report difficulty without changing the therapy plan.	Repeated use and barrier resolution support the approved compensatory strategy in daily life.	Partial. Proxi can provide reminders, log practice, and alert the navigator or therapist to difficulty.	Yes	Beneficiary or caregiver; navigator; therapist on trigger.
FI08. Reassess progress and revise the plan	Evaluate whether function, assistance, safety, or the person's goal changed and decide whether to continue, alter, or end the intervention.	NICE's goal-based rehabilitation requires professional evaluation of functional outcome and changing need.	No. Proxi can summarize reports and observed measures but cannot interpret or revise therapy.	Yes	Occupational therapist or qualified rehabilitation clinician; beneficiary participates.

Acute-change, pain, and delirium detection#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
AC01. Establish and teach the observable baseline	Record the person's usual alertness, communication, mobility, intake, sleep, behavior, and pain expression and teach the dyad which changes warrant prompt contact.	NICE §§1.7.1, 1.8.3–1.8.5, and 1.9.1 distinguishes baseline dementia from pain, delirium, and other causes of change.	Partial. Proxi can organize approved baseline observations and warning-sign education; a clinician defines individualized clinical warnings.	Yes	Beneficiary and caregiver; navigator; licensed clinician for individualized clinical guidance.
AC02. Provide an easy human reporting route	Give the beneficiary and caregiver a usable way to report a sudden or concerning change and explain when to use emergency services.	Early reporting supports NICE's direction to assess possible pain, delirium, and clinical causes rather than dismiss change.	Partial. Proxi can present the approved route and connect the caller but cannot replace the human or emergency response.	Yes	Navigator or human responder; beneficiary and caregiver.
AC03. Capture the new observation	Ask what changed, when it began, who observed it, current location, recent transition, medicines, intake, falls, pain behavior, and other reported symptoms.	NICE recommends structured assessment of possible reasons for distress and observational pain information when self-report is limited.	Partial. Proxi can guide approved questions and preserve source and timing without diagnosing.	Yes	Beneficiary or caregiver reports; trained staff receives; clinician reviews.
AC04. Determine immediate urgency and disposition	Decide whether the change requires emergency response, same-day assessment, urgent clinician contact, or planned review.	Individual urgency and disposition for delirium, pain, injury, or illness are clinical decisions.	No. Proxi cannot set clinical urgency or disposition.	Yes	Licensed clinician, emergency professional, or other authorized urgent responder.
AC05. Administer an appropriate observational pain screen	When self-report is unreliable and a clinician or protocol indicates it, observe and record the configured pain behaviors using the approved tool.	NICE recommends a structured observational pain tool alongside clinical assessment for moderate or severe dementia or inability to self-report.	Partial. Proxi can present the configured items and calculate a permitted score; it cannot select or interpret the tool clinically.	Yes	Trained nurse or care-team member administers; licensed clinician interprets.
AC06. Assess pain, delirium, illness, and medication causes	Perform the clinical history, examination, testing, medication review, and differential assessment needed to determine the cause.	NICE specifically directs teams to check and address pain, delirium, and other clinical causes.	No. Proxi can assemble records and observations but cannot diagnose.	Yes	Physician, advanced practice clinician, nurse within scope, pharmacist, or other licensed professional.
AC07. Decide and communicate treatment	Select treatment, monitoring, testing, medication action, or escalation and explain the plan to the beneficiary and caregiver.	NICE places treatment of pain, delirium, and other causes with qualified health professionals.	No. Proxi can draft from the clinician's authorized decision but cannot select treatment.	Yes	Treating licensed clinician; pharmacist or therapist as applicable.
AC08. Carry out the coordination around the clinical plan	Arrange appointments, tests, transport, pharmacy action, equipment, and follow-up and tell the dyad whom to contact if the condition changes.	Closing the surrounding work helps the clinical response occur promptly and consistently.	Full where connected. Proxi can coordinate connected administrative work and reminders; humans resolve exceptions and deliver care.	Partial	Care navigator or clinical coordinator; providers, pharmacy, lab, transport, and vendors.
AC09. Recheck and update the baseline	Ask whether the change resolved, worsened, or became the new baseline and obtain clinical reassessment before treating a material change as permanent.	NICE recommends repeat pain assessment and continued attention to clinical causes of behavior or distress.	Partial. Proxi can schedule follow-up and compare observations; clinicians interpret persistence and update clinical conclusions.	Yes	Care navigator; licensed clinician; beneficiary and caregiver.

Nutrition, hydration, and swallowing support#

Task	What the step entails	Evidence/value basis	What Proxi can do	Person required?	Person or role
NU01. Ask about eating, drinking, and mealtime difficulty	Ask about appetite, fluid intake, weight change, chewing, coughing, choking, pocketing food, fatigue, access to food, and caregiver burden at meals.	NICE §§1.10.6–1.10.8 recommends supporting eating and drinking and obtaining swallowing expertise when safety is a concern.	Partial. Proxi can administer approved questions and surface choking, dehydration, or weight-loss concerns.	Yes	Beneficiary or caregiver; navigator or trained care-team member; clinician reviews positive findings.
NU02. Describe the pattern and practical barriers	Record foods and fluids offered and taken, time of day, positioning, environment, oral or dental difficulty, supply, cooking, transport, and assistance available.	NICE emphasizes nutritional needs and safe eating; practical context helps distinguish service barriers from clinical problems.	Partial. Proxi can organize a structured food, fluid, and mealtime report without diagnosing.	Yes	Beneficiary or caregiver; navigator; clinician, dietitian, or speech-language pathologist reviews as needed.
NU03. Respond to immediate choking or severe dehydration concern	Use the approved emergency route for current choking, breathing difficulty, altered consciousness, or another potentially emergent condition.	Swallowing safety and acute hydration risk require prompt qualified response, not routine navigation.	Partial. Proxi can connect emergency help and pass reported facts but cannot determine clinical severity.	Yes	Human responder; emergency services or licensed clinician.
NU04. Perform clinical nutrition and medical assessment	Evaluate weight loss, dehydration, oral health, gastrointestinal symptoms, medication effects, mood, infection, and other reversible causes and determine needed testing or treatment.	NICE recommends support based on nutritional need; determining the cause of poor intake is clinical work.	No. Proxi can assemble history and records but cannot diagnose or prescribe treatment.	Yes	Physician, advanced practice clinician, nurse, dietitian, dentist, or other qualified professional within scope.
NU05. Perform swallowing assessment	Assess swallowing safety and determine whether positioning, texture, supervision, therapy, or another intervention is clinically indicated.	NICE recommends involving a speech and language therapist when eating or drinking safety is a concern.	No. Proxi cannot assess aspiration risk or prescribe texture or swallowing strategies.	Yes	Speech-language pathologist and treating clinician.
NU06. Create the approved nutrition or swallowing plan	Specify nutrition goals, meal pattern, assistance, oral care, positioning, texture, fluid strategy, monitoring, and help-seeking instructions.	NICE supports eating and drinking according to nutritional needs and clinician-led decisions when swallowing safety is involved.	No. Proxi can format and distribute an authorized plan but cannot create it independently.	Yes	Dietitian, speech-language pathologist, clinician, dentist, and beneficiary as applicable.
NU07. Resolve food, supply, and appointment barriers	Arrange meals, groceries, adaptive utensils, dental care, transportation, clinical visits, or other supports required by the approved plan.	Practical access turns clinical recommendations into daily food and fluid support.	Full where connected. Proxi can match approved resources, schedule, order, remind, and track delivery; people resolve exceptions.	Partial	Care navigator; meal provider, retailer, transport, vendor, dental or clinical office.
NU08. Teach and support the approved mealtime routine	Demonstrate only the clinician-approved assistance, positioning, pacing, texture, oral-care, and monitoring steps and confirm the caregiver can use them.	NICE supports daily eating and drinking and assigns swallowing-safety recommendations to qualified professionals.	Partial. Proxi can display approved instructions and reminders; hands-on training and correction remain human.	Yes	Speech-language pathologist, dietitian, nurse, occupational therapist, or trained caregiver educator; caregiver and beneficiary.
NU09. Monitor intake, comfort, weight, and new warning signs	Follow the authorized monitoring plan; ask about actual intake and tolerance; and obtain prompt clinical reassessment for worsening, choking, dehydration, or weight loss.	NICE's nutrition and swallowing guidance requires ongoing response to need and safety, not a one-time referral.	Partial. Proxi can collect configured observations, schedule follow-up, and surface thresholds; clinicians interpret and change the plan.	Yes	Beneficiary or caregiver; navigator; dietitian, speech-language pathologist, nurse, or clinician on trigger.

Requirement, value, and clinical classification#

Task	GUIDE standing	Customer-value position	Clinical lane	Why
LC01. Offer recurring coaching	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Offering a voluntary coaching relationship is preference and service work.
LC02. Choose the immediate coaching goal	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	The caregiver chooses the practical result they want.
LC03. Understand what happens now	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine context collection is delegable; symptoms or safety concerns move to a clinician.
LC04. Select an approved coaching lesson	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Approved education can be matched routinely unless the reported need is clinical.
LC05. Practice the skill	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine rehearsal is non-clinical; individualized medical or safety questions escalate.
LC06. Agree on one home action	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	A practical action is delegable when it does not change clinical care.
LC07. Check what happened	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Follow-up is routine until the report contains a new clinical concern.
LC08. Adapt, continue, or escalate	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Coaching may adapt within scope; clinical severity and treatment remain licensed work.
BD01. Receive the behavior or distress concern	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Human intake is routine, while severe distress or danger needs clinical response.
BD02. Describe the behavior observably	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Recording observable facts does not assign a diagnosis or cause.
BD03. Identify pattern and context	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Pattern collection is delegable; sudden or medically concerning change escalates.
BD04. Assess possible medical causes	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Determining pain, delirium, illness, or medication contribution is clinical assessment.
BD05. Assess unmet needs and environmental contributors	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine needs and environment review is delegable, with clinical exceptions.
BD06. Determine urgency and treatment	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Urgency, diagnosis, disposition, and treatment cannot be delegated.
BD07. Build the non-drug response plan	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Trained staff may use approved strategies; individualized clinical treatment requires review.
BD08. Coach the people who will use the plan	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Approved coaching is delegable, while clinical questions return to the professional.
BD09. Review outcomes and revise	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine observation supports revision; worsening symptoms or treatment changes are clinical.
FL01. Ask about falls and instability	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Screening questions can be delegated; a positive screen needs clinical review.
FL02. Respond to a fall that may need immediate care	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	The responder connects the person and reports the facts; the receiving clinician or emergency professional determines injury severity and disposition.
FL03. Perform the clinical fall-risk assessment	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Examination and interpretation of modifiable risk are licensed work.
FL04. Review the home and daily environment	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	A checklist is delegable; individualized safety recommendations may require OT or clinical review.
FL05. Review medicines that may increase fall risk	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Medication contribution and change decisions require a pharmacist or prescriber.
FL06. Select the fall-reduction interventions	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Treatment and intervention suitability follow professional assessment.
FL07. Arrange the selected services and equipment	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Scheduling and obtaining already selected supports are logistical.
FL08. Teach and implement the approved plan	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Approved teaching is delegable; individualized correction and new symptoms escalate.
FL09. Follow up after intervention or another fall	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Completion tracking is routine; another fall or functional change requires reassessment.
WN01. Ask about wandering and getting-lost signs	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Structured collection is delegable; new change or danger triggers review.
WN02. Act when the person is currently missing	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	The task requires immediate human and public-safety action, but not medical judgment; a separate sudden-change task carries any clinical assessment.
WN03. Assess sudden change and individualized risk	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Cause, risk, and restrictions require clinical or safeguarding judgment.
WN04. Map patterns, triggers, and likely destinations	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Pattern collection is routine, with clinical review for sudden or unsafe change.
WN05. Build a prevention routine	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine supports can be planned non-clinically; individualized restrictions require review.
WN06. Make the home safer	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	General safeguards are practical; restraint, egress, and individualized risk need qualified review.
WN07. Arrange identification and location supports	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	The person chooses among identification and notification options.
WN08. Create the missing-person response plan	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Compiling current facts and contacts is preparedness work.
WN09. Rehearse the plan	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Practice tests understanding without making a clinical decision.
WN10. Review after an incident or meaningful change	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Operational lessons are delegable; changed risk or cause requires qualified reassessment.
SV01. Ask about sensory function and devices	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine questions are delegable; new symptoms trigger professional review.
SV02. Verify prior recommendations and follow-up	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Record and referral status verification is factual.
SV03. Perform sensory assessment and treatment	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Diagnosis, prescribing, fitting decisions, and treatment stay with licensed professionals.
SV04. Arrange appointments and access	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Scheduling and barrier resolution implement an existing referral.
SV05. Obtain the prescribed device or correction	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Procurement is logistical; professional fitting or intolerance requires review.
SV06. Establish the daily device routine	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine maintenance is non-clinical; fit, pain, or performance problems return to the provider.
SV07. Adapt all service communication	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Applying known communication preferences is not medical interpretation.
SV08. Check whether correction helped	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Reported usability is routine; persistent or worsening impairment needs reassessment.
MU01. Confirm the approved regimen before support	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Staff can verify presence of an approved regimen; conflicts go to the prescribing clinician.
MU02. Ask how medicines are actually being used	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Report collection is delegable; discrepancies require clinical review.
MU03. Identify the specific adherence barrier	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Practical barriers are routine; symptoms and treatment concerns are clinical.
MU04. Let the beneficiary choose feasible support	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Preference choice is non-clinical unless an option would change the regimen.
MU05. Obtain clinical decisions needed to simplify the routine	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Dose, timing, formulation, and treatment changes require prescribing authority.
MU06. Resolve supply, packaging, and delivery barriers	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Administrative access work implements an already approved regimen.
MU07. Set up the selected reminder or organization support	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Setup follows the approved schedule without changing treatment.
MU08. Teach back the approved schedule	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Approved instructions may be reinforced; clinical questions escalate.
MU09. Monitor use and new concerns	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine observation is delegable; symptoms, refusal implications, and discrepancies are clinical.
MU10. Clinically respond and update the approved plan	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Reconciliation and treatment change require a prescriber.
TR01. Detect the transition and reach the dyad	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Event detection and outreach are factual and logistical.
TR02. Obtain the discharge and transfer information	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Record retrieval does not interpret conflicting instructions.
TR03. Conduct the early recovery call	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine human follow-up is delegable with clinical backup for concerns.
TR04. Check health status and warning signs	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Approved questions may be asked by trained staff; positives require interpretation.
TR05. Determine the clinical response	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Symptom urgency, diagnosis, and disposition are clinical.
TR06. Reconcile post-transition medicines	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Medication reconciliation and final regimen decisions require prescribing authority.
TR07. Verify appointments, equipment, and home services	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Verification and administrative follow-through are factual.
TR08. Resolve practical and communication gaps	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine barriers are navigational; conflicting clinical instructions escalate.
TR09. Review needs, wishes, and plans after the transition	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Preference review is non-clinical; clinical plan changes require a clinician.
TR10. Continue recovery follow-up until the handoff works	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Tracking is routine; unresolved clinical issues remain clinician-owned.
FP01. Offer planning without pressure	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Readiness and participation are beneficiary choices.
FP02. Elicit goals, values, and future preferences	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	The beneficiary states their own values and preferences.
FP03. Identify trusted decision supporters	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Naming preferred supporters is a personal choice, not a medical decision.
FP04. Explain planning options and documents	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Approved general education is delegable; medical and legal advice require professionals.
FP05. Arrange professional planning conversations	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Referral and scheduling do not provide the professional advice.
FP06. Complete clinical counseling and medical orders	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Capacity, individualized medical counseling, and medical orders are nondelegable.
FP07. Organize and share completed documents	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Authorized document organization and distribution are administrative.
FP08. Revisit the plan after change and at agreed intervals	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Preference review is routine; clinical or legal revisions go to the responsible professional.
MS01. Learn the person's interests and identity	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	The person supplies their own preferences and life history.
MS02. Understand current connection and barriers	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Practical barriers are navigational; depression, distress, or safety concerns escalate.
MS03. Assess clinical or therapeutic suitability when needed	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Individualized safety and therapy suitability require qualified assessment.
MS04. Build a small, personalized activity plan	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Preference matching is routine when no clinical safety issue is present.
MS05. Connect to suitable people and programs	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Connection follows the person's choice and any completed suitability review.
MS06. Remove practical participation barriers	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Transport, format, cost, and accompaniment are logistical.
MS07. Check actual participation and experience	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Feedback collection is routine; distress or functional change triggers review.
MS08. Adapt or clinically reassess the activity plan	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine preferences can be changed non-clinically; safety and therapy changes require review.
FI01. Choose a beneficiary-defined functional goal	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	The beneficiary chooses the daily-life result that matters.
FI02. Describe current performance and context	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Observation can be collected routinely; safety or clinical causes trigger review.
FI03. Perform the functional assessment	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Functional examination and interpretation require a qualified therapist or clinician.
FI04. Create the rehabilitation or reablement plan	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Therapy design and safety limits are nondelegable professional work.
FI05. Arrange therapy, devices, and environmental support	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Coordination implements a professional plan.
FI06. Teach the approved strategy	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Approved practice support is delegable; individualized correction remains professional.
FI07. Support practice and remove barriers	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine reminders are delegable; difficulty or decline returns to the therapist.
FI08. Reassess progress and revise the plan	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Functional outcome interpretation and therapy revision require a qualified professional.
AC01. Establish and teach the observable baseline	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine observations are delegable; individualized medical warnings require clinician input.
AC02. Provide an easy human reporting route	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Access instructions and connection are non-clinical.
AC03. Capture the new observation	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Fact collection is delegable; reported danger or symptoms trigger clinical review.
AC04. Determine immediate urgency and disposition	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Individualized urgency and disposition are nondelegable.
AC05. Administer an appropriate observational pain screen	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Configured administration may be delegated; tool choice and interpretation are clinical.
AC06. Assess pain, delirium, illness, and medication causes	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Differential assessment, examination, and diagnosis are licensed work.
AC07. Decide and communicate treatment	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Treatment selection and individualized counseling require the treating clinician.
AC08. Carry out the coordination around the clinical plan	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Scheduling and administrative execution follow the authorized plan.
AC09. Recheck and update the baseline	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Follow-up observations are delegable; persistent change needs clinical interpretation.
NU01. Ask about eating, drinking, and mealtime difficulty	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine questions are delegable; positive swallowing or nutrition concerns escalate.
NU02. Describe the pattern and practical barriers	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Practical context is delegable; clinical signs require professional review.
NU03. Respond to immediate choking or severe dehydration concern	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	A human invokes the emergency route and conveys the report; the receiving clinician or emergency professional determines severity and disposition.
NU04. Perform clinical nutrition and medical assessment	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Cause, diagnosis, testing, and treatment are clinical.
NU05. Perform swallowing assessment	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Aspiration risk and swallowing recommendations require a speech-language pathologist or clinician.
NU06. Create the approved nutrition or swallowing plan	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical judgment required	Nutrition treatment, texture, and swallowing-safety plans require qualified professionals.
NU07. Resolve food, supply, and appointment barriers	Beyond the public GUIDE minimum	Additional evidence-backed value	No clinical judgment	Resource and appointment coordination are logistical.
NU08. Teach and support the approved mealtime routine	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Approved strategies may be reinforced; individualized changes return to professionals.
NU09. Monitor intake, comfort, weight, and new warning signs	Beyond the public GUIDE minimum	Additional evidence-backed value	Clinical review on trigger	Routine observations are delegable; deterioration and warning signs require clinical review.