This is a106-task candidate work inventory, not106 separate services or proven Proxi outcomes. Each task's classification names its baseline interface and either a distinct candidate additional result or an explicit no-extra baseline-only result. Required assessment, medication, transition, caregiver, access, referral and care-plan work stays in the base service; it is never withheld, resold or counted twice because an enhancement is declined. SV07 accessibility and AC02 human access need no optional activation.
Before making a promise. Under O-052, select whether Proxi furnishes the decisive act with a funded employee/contractor or only supplies preparation, access, barrier resolution and closed-loop coordination around independent outside care. Name the actual performer, service area, capacity/backup, who pays, expected useful result and truthful non-success return. D-012 in-scope GUIDE work remains paid Proxi work; an outside label never makes our contracted fulfillment free. No abstract Participant clinician, releaser or navigator performs routine work.
Automation and useful human entry. A clear authenticated report, preference, goal or approved-content choice can proceed digitally. L1 performs actual administrative pursuit; L2 performs a required/requested nonclinical service, clarification or relationship act; the exact licensed professional performs protected judgment. A library match is not a navigator review. Current authoritative clinical/therapy products may be reused only for the same applicable subject/question/instruction with unchanged conditions; new symptoms, conflicts, changed location, new questions or genuinely due reassessment open the exact professional act. No generic RN/L2/CMO blessing.
Daily Companion boundary. D-023 permits source-attributed input, approved information, reminders and routed help requests. It is not continuous monitoring, emergency response, diagnosis, clinical assessment, synchronous human access, caregiver assessment, human GUIDE contact, service completion or payment evidence. Caregiver pulse belongs to the caregiver, not the beneficiary; silence and stale/conflicting input remain unknown. A routed request stays open until the actual human returns.
Time and closure. The paid person performs the specified act, not a row-sized time block. Count one real shared encounter once and retain each distinct actual service result. Existing baseline episode estimates are not an enhanced-service price or time cap; new occurrence, low/ordinary/high incremental minutes, contractor fees, travel and availability remain O-052. Source collection, an appointment, transmission, acceptance, actual professional delivery, intended use and later usefulness are separate results. Additional outreach needs a person-specific useful reason and agreed next action; no billing-filler or quality-only contact.
Evidence fit. The linked sources support service-design ingredients, not efficacy of Proxi's AI or a universal protocol. NICE is UK guidance, not U.S. law/licensure or GUIDE authority; its structured cognitive/rehabilitation recommendations retain their population limits. WHO self-help is not proof of AI-only furnished care. AHRQ RED's clinical-staff call is not an endorsement of replacing clinical follow-up with AI or L2; the Proxi split is an explicit adaptation. Exact clinical instruments, state-specific planning documents and professional instructions still need their own approved source. See the source register and retrieval limits; the executed Agreement remains O-PA-001.
Professional selection#
For every licensed act, record the actual clinical subject, current physical location/time, applicable provider-location rules, exact question, license/scope/modality and the individual accepting it. A caregiver reporting beneficiary symptoms does not relocate beneficiary care; separate caregiver care has its own authority/result. Two subjects keep two results with one shared intake. The table below selects an act, not a universal chain or a list of people who all attend.
| Actual question or work | Real person/capacity | Expected act and return | Review |
|---|---|---|---|
| Nonclinical choice, ordinary coaching or application of an approved skill | Puerto Rico GUIDE navigator with current topic/format capability | Clarify the requested choice or deliver the selected safe coaching/application; return the person's response, correction, intended use and remaining need. No medical, legal-capacity or clinical suitability conclusion. | |
| Manual office/pharmacy/vendor fact, inaccessible source or transaction failure | Philippine L1 support | Obtain the exact administrative fact/status, preserve source/time and return it. Nursing education supplies no U.S. clinical authority. | |
| Actual nursing assessment, clinical symptom triage under the accepted nursing protocol or nursing-technique instruction | U.S. clinical RN | Personally assess the assigned nursing question within scope and return nursing disposition/instructions or the medical question needing a prescriber. No medical diagnosis or unapproved regimen change. | |
| Actual licensed psychosocial/behavioral assessment or treatment, including caregiver-own care | U.S. LCSW/behavioral clinician | Assess the actual subject within scope and return the attributable behavioral-care result. Ordinary caregiver stress coaching alone does not trigger this act. | |
| Medical cause/differential, diagnosis, treatment, prescribing, reconciliation authority or medical order | U.S. prescribing/E-M clinician | Perform necessary medical history/examination/judgment and return the authorized disposition, regimen or instruction. O-028 controls the exact medication authority; a regular RN is not its substitute. | |
| Medication contribution, product administration or packaging compatibility | Actual pharmacist, paid if contracted to fulfill Proxi's promise | Return the product/medication assessment within actual jurisdiction/scope and obtain any needed prescriber agreement. Do not substitute for gait, swallowing or medical diagnosis. | |
| Gait/balance therapy versus everyday-task rehabilitation | Actual PT or OT/rehabilitation professional, paid if Proxi-furnished | PT owns the selected mobility act; OT/appropriate rehabilitation professional owns the functional goal/plan/teaching/revision. Return that exact component, not a blanket medical safety approval. | |
| Swallowing safety versus nutrition or oral/dental care | Actual SLP, dietitian or dentist, each selected only for their act | SLP returns swallowing assessment/instructions; dietitian returns nutrition work; dentist returns oral/dental work; medical treatment remains the treating clinician's act. Separate authors and pending components. | |
| Sensory diagnosis, clinical fitting or treatment | Actual audiologist, optometrist or ophthalmologist | Return the selected sensory assessment/fitting/treatment. Retail pickup or a generic device checklist is not this service. | |
| Physical home observation/installation, egress or practical hazard correction | Actual social worker/home-safety specialist/contractor in the approved capacity | Return the structured onsite observations or permitted physical correction. D-028 work may be reused only when it is the same accepted visit. Medical judgment, liberty restrictions and uncovered legal/code questions are separate. | |
| Uncovered state-law document, agent authority or restriction question after facts are complete | Legal Counsel or an actual outside attorney for the person's own advice | Resolve only the exact legal question. General education and naming a supporter do not execute a document or establish legal authority; no attorney is added to a clean routine case. |
If an accepted professional cannot respond, use the owning base SOP's preapproved backup and response rule. A failed transfer is unfinished work, not clinical acceptance or safe waiting. Independent emergency-safe help and unaffected work continue; no improvised professional or new generic specialist is introduced.
Longitudinal caregiver coaching#
When and useful result. A caregiver asks for another practical strategy or a prior agreed action is still difficult; no separate sales or billing call. The added result is repeated coaching around a caregiver-chosen situation; required caregiver education/support continues independently.
Prepare once. The caregiver's goal, incident description, approved lesson, chosen action, last application response and preferred next contact. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. LC01-04 can prepare and accept a clear choice digitally. LC05-06 are one selected paid L2 rehearsal/application act; LC07 collects the later report, and LC08 adds actual coaching or a protected response only when needed. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return the action, intended use, help route, application result and later caregiver-owned tried/helped/not-tried/unknown result. Patient refusal does not mean caregiver failure. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Present approved service/formats/times and record preference. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Elicit the current situation and draft a concrete goal. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Guide a structured narrative and preserve the caregiver's words and concern cues. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Match the caregiver-confirmed goal to the approved lesson taxonomy and let the caregiver choose; prepare actual application without an L2 fit blessing. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Run approved roleplay, repetition, and feedback prompts. | Yes for the actual selected human act | Puerto Rico GUIDE navigator (Puerto Rico GUIDE navigator). Paid human observes rehearsal, corrects misunderstanding, and returns the demonstrated use/help need. Count the actual shared encounter once; additional incidence/minutes/fees remain O-052. | |
| 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. | Draft a small action, reminder, and success/failure check. | Yes for the actual selected human act | Puerto Rico GUIDE navigator (Puerto Rico GUIDE navigator). Paid human confirms one bounded nonclinical action and help route. Count the actual shared encounter once; additional incidence/minutes/fees remain O-052. | |
| 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. | Schedule follow-up, restate the action, and summarize the report. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Suggest another approved lesson and surface configured escalation cues. | Yes for the actual selected human act | Puerto Rico GUIDE navigator (Puerto Rico GUIDE navigator); triggered U.S. RN or behavioral clinician (U.S. clinical RN, U.S. LCSW/behavioral clinician) or medical clinician (U.S. prescribing/E-M clinician). Paid human adapts the coaching or makes the accepted direct protected handoff. Count the actual shared encounter once; additional incidence/minutes/fees remain O-052. |
Behavior and distress prevention#
When and useful result. A current distress/behavior report needs more follow-through than the base episode already supplied. The added result is pattern-to-response follow-through beyond the already-due assessment/training; required Assessment and caregiver behavior support continues independently.
Prepare once. Observable acts/words, onset, previous usual observations, antecedent/context, recent medicines/transition, current clinical instructions and reported concerns—not a guessed cause. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. BD01-03/05 collect facts. A current medical concern uses BD04/06's exact professional; BD07-09 are the selected human-owned response/coaching/revision, not AI treatment authorship. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return the authorized practical response, who will use it, stop/help instructions and reported change. Persistent/worsening symptoms remain a protected question, never ordinary behavior by default. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Conduct the routine intake, capture location/timing, and surface danger or severe-distress cues. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Prompt for observable facts, timing, source, and impact without diagnostic labels. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Organize antecedents, consequences, routines, places, and baseline differences. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Assemble symptoms, medicines, history, and observations. | Yes for the actual selected human act | Medical cause/differential, diagnosis and treatment: U.S. medical clinician. Only when needed, U.S. RN returns the nursing component, paid pharmacist the medication component and U.S. behavioral clinician only the psychosocial component. Each returns its own scoped result; no behavioral professional is assigned the whole medical-cause assessment. | |
| BD05. Assess unmet needs and environmental contributors | Capture the person's reported unmet needs and practical environment facts; 'assess' here means factual nonclinical review. Medical cause, therapeutic suitability and individualized risk are separate protected acts. | NICE recommends exploration of reasons for distress and psychosocial and environmental intervention as initial and ongoing management. | Capture reported toileting, hunger, stimulation, routines, communication and environment facts; prepare bounded nonclinical options without causal, therapeutic or safety conclusions. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. Protected medical interpretation is BD04/06; an actual therapeutic/environmental assessment uses Select the professional for this act. | |
| 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. | Present the evidence and authorized options without selecting one. | Yes for the actual selected human act | Actual authorized U.S. RN/behavioral clinician or medical clinician (U.S. clinical RN, U.S. LCSW/behavioral clinician, U.S. prescribing/E-M clinician); emergency/protective authority as outside endpoint (External party). The actual paid authorized professional determines urgency, disposition, and treatment when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Prepare candidate approved nonclinical strategies and source facts for the selected qualified human; AI does not author treatment, determine cause or select a clinical/safety intervention. | Yes for the actual selected human act | Puerto Rico GUIDE navigator (Puerto Rico GUIDE navigator) for approved nonclinical strategy; actual U.S. clinician or paid contracted therapist for protected content (U.S. clinical RN, U.S. LCSW/behavioral clinician, External party). Paid human selects and authorizes the person-specific response strategy within scope. Count the actual shared encounter once; additional incidence/minutes/fees remain O-052. | |
| 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. | Render instructions, run approved rehearsal, and send reminders. | Yes for the actual selected human act | Puerto Rico GUIDE navigator (Puerto Rico GUIDE navigator) in verified educator capacity; actual clinician only for a triggered protected question. Paid human coaches and corrects the people who will use the plan. Count the actual shared encounter once; additional incidence/minutes/fees remain O-052. | |
| 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. | Compare reported frequency, duration, distress, safety, and burden with baseline. | Yes for the actual selected human act | Puerto Rico GUIDE navigator (Puerto Rico GUIDE navigator) for nonclinical revision; actual U.S. clinician for worsening symptoms/treatment (U.S. clinical RN, U.S. LCSW/behavioral clinician, U.S. prescribing/E-M clinician). Paid human interprets results and revises the human-owned plan. Count the actual shared encounter once; additional incidence/minutes/fees remain O-052. |
Fall-prevention service#
When and useful result. A fall, positive approved screen, unfinished intervention or requested prevention work exists; the already-required assessment is not sold again. The added result is implement and follow through on a specific fall-reduction plan; required Assessment fall risk and care coordination continues independently.
Prepare once. Incident/injury report, current location, existing risk assessment, exact medication list, mobility/environment reports, accepted plan and actual equipment/service status. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. FL01/07/09 collect and coordinate digitally where supported. FL02 invokes the immediate route. FL03/05/06 use each domain's professional. FL04/08 use the actual paid onsite/therapy/technical worker if Proxi furnishes them; otherwise coordination-only. Read each task below for its exact software result and actual paid human entry.
Return and next action. Distinguish assessed risk, selected intervention, installation/training, actual use and new fall. An order or appointment is not delivered intervention; preserve declined/unavailable/unfinished work. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Administer approved questions and collect dates/circumstances. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Capture current location/report and connect the urgent route. | Yes for the actual selected human act | Philippine first-answer support (Philippine L1 support) for live capture/connection; actual U.S. clinician or outside urgent/emergency endpoint (U.S. clinical RN, U.S. prescribing/E-M clinician, External party). Paid L1 performs only live nonclinical capture/connection inside the existing roster; the authorized clinical or public-safety recipient accepts the live concern and completes the urgent clinical/emergency handoff. Count the same event once; no extra enhanced contact is manufactured. | |
| 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. | Assemble history and configured scores. | Yes for the actual selected human act | Actual authorized U.S. RN or medical clinician and/or paid contracted PT/OT within exact scope (U.S. clinical RN, U.S. prescribing/E-M clinician, External party). The actual paid authorized professional examines and interprets fall risk when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Guide checklist and organize reports/photos. | Yes for the actual selected human act | Paid contracted OT/home-safety professional (External party); reuse D-028 onsite work only when it is the same accepted event. If Proxi sells this as furnished care, a paid contracted professional observes the actual environment and returns individualized safety recommendations; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Assemble reconciled list and symptom reports. | Yes for the actual selected human act | Actual prescribing medical clinician (U.S. prescribing/E-M clinician) or paid contracted pharmacist (External party). The actual paid authorized professional assesses medication contribution and any change when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Present assessed risks and approved intervention options. | Yes for the actual selected human act | Actual medical clinician plus paid contracted PT/OT/pharmacist/sensory professional only for each scoped selection (U.S. prescribing/E-M clinician, External party). The actual paid authorized professional selects the appropriate fall-reduction intervention when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Prepare referrals, schedule, remind, and track equipment/service status. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Deliver approved materials and reminders. | Yes for the actual selected human act | Paid contracted PT/OT/equipment professional or actual U.S. RN within scope (External party, U.S. clinical RN). If Proxi sells this as furnished care, the selected Proxi-employed or Proxi-contracted professional demonstrates and corrects the approved technique/device/environmental use; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Track completion and conversationally collect new falls/barriers. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. |
Wandering and missing-person preparedness#
When and useful result. Reported getting-lost/exit incidents, a missing-person plan gap or requested preparedness triggers this work; a currently missing person takes WN02 immediately. The added result is current preparedness, identification and a rehearsed response; required Assessment wandering safety and caregiver training continues independently.
Prepare once. Current missing status/location last seen, source/time, photograph and description, contacts/destinations, permissions, supervision choices, existing safeguards and egress constraints. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. Routine pattern/plan assembly is digital. WN02 uses an actual human/public-safety route without waiting for intake perfection. WN03/06 separate clinical cause, liberty/egress and physical work. WN09 is one paid L2 safe rehearsal, not a live missing-person simulation. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return an accessible current plan, permitted contacts, rehearsal corrections and incident result. Found is not a completed clinical cause assessment; keep the latter open when triggered. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Administer approved questions and record incidents/sources. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| WN02. Act when the person is currently missing | For a current missing report, give the approved immediate local public-safety route and connect actual human help; prepare current source facts and permitted disclosures without waiting for routine follow-up. | NIA recommends preparing identification, photographs, contacts, and safeguards so a missing person can be found safely. | Display the current approved plan and prepare attributed last-seen/photo/contact facts; no autonomous public-safety command or photo/location disclosure. | Yes for the actual selected human act | Philippine first-answer support (Philippine L1 support) for live connection; caregiver and public-safety/search authority are outside actors (Caregiver/authorized representative, External party). Philippine L1 support captures the current missing report and connects the approved public-safety route immediately; source/current-event and disclosure confirmation do not delay caller911 instructions. Caregiver/public-safety response is not automatically Proxi clinical labor; failed acceptance remains open. | |
| 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. | Prepare incident history and possible source gaps. | Yes for the actual selected human act | Actual U.S. RN, behavioral clinician, or medical clinician for the protected act (U.S. clinical RN, U.S. LCSW/behavioral clinician, U.S. prescribing/E-M clinician); protective authority is outside (External party). The actual paid authorized professional assesses cause, individualized risk, safeguarding, and any restriction when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Organize incidents, routes, times, routines, and recurring context. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Draft a routine from approved options and reminders. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Guide checklist and source approved products. | Yes for the actual selected human act | The selected paid OT/home-safety professional returns within-scope physical observations, product/environment fit and permitted safety recommendations. A genuine clinical restriction uses the exact clinician; an unresolved liberty, agent-authority, fire/code or state-law question uses Legal Counsel or the actual local code authority. Hold only the affected lock/disclosure/installation; independent emergency-safe help continues. | |
| 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. | Present approved options, prepare enrollment, and prompt updates. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Assemble current photo, description, contacts, destinations, hazards, and instructions. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Prepare a safe hypothetical rehearsal from the current response plan; no live missing-person or patient demonstration. | Yes for the actual selected human act | Puerto Rico GUIDE navigator — safe human rehearsal/application. Puerto Rico GUIDE navigator observes the selected safe rehearsal, corrects misunderstood contacts/actions and records intended use/help route under D-019. Count the same coaching event once; additional minutes remain O-052. | |
| 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. | Reconstruct the event, compare plan performance, and conduct the ordinary lessons-learned interview. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. |
Hearing and vision optimization#
When and useful result. A sensory-care recommendation, device/access barrier or person request needs follow-through. SV07 accommodations apply even if this enhancement is declined. The added result is make selected sensory support actually obtainable and usable; required Assessment hearing referral and accessible service delivery continues independently.
Prepare once. Reported difficulty, existing recommendation, provider/device identity, current instructions, appointment/order status, communication preferences and actual tolerance/use report. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. Facts, reminders and access are digital; L1 pursues a genuinely manual route. SV03 belongs to the exact sensory professional. Procurement is not fitting or clinical treatment; retail/OTC support is not automatically prescription care. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return received recommendations, actual device acquisition/fitting when applicable, a chosen daily routine and reported usability. Device failure never removes basic accessible communication. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Administer approved questions and gather device/appointment history. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Retrieve connected records, identify gaps, prepare record requests, and track due follow-up. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Assemble history and prior recommendations. | Yes for the actual selected human act | Paid contracted audiologist/optometrist/ophthalmologist or other exact sensory professional (External party); Proxi medical clinician only if separately authorized for that act (U.S. prescribing/E-M clinician). If Proxi sells this as furnished care, a paid contracted professional performs diagnosis, fitting/treatment selection, and professional response; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Schedule, remind, prepare transport/accommodation requests, and track barriers. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Track orders, vendors, pickup, repair, replacement, and maintenance reminders. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Create approved storage, cleaning, charging, battery, and troubleshooting prompts. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Apply stored caption, print, contrast, volume, pace, language, and format preferences. | No for the digital act; separate physical/recovery work | No person for formatting; Philippine L1 support — actual access recovery; actual communicator's service time is counted once. No person for applying known digital formatting. Actual communicator verifies usability within the base service; L1/accessibility support enters only for a real failure. | |
| 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. | Schedule follow-up and collect use, benefit, and tolerance reports. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. |
Personalized medication-use support after clinician approval#
When and useful result. The person reports a practical barrier or requests a support change; no new reconciliation or contact is manufactured for a quiet reminder month. The added result is barrier-specific daily use support after an authorized regimen; required Medication management and caregiver instruction continues independently.
Prepare once. Current authoritative regimen/instructions, actual-use report, pharmacy/supply facts, selected practical option, who administers and any new symptom/conflict/question. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. MU01-04 collect and capture choice. MU05/10 use actual medication authority. MU06 is access; MU07's digital setup is separate from physical setup/administration. MU08 faithfully explains an existing instruction, never invents missed-dose/crushing or timing advice. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return the selected support, actual supply/setup, intended method and current-use report. Sent reminders are not taken doses; facility administration and household assistance remain different actors. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Compare source identity/date/instructions and surface conflicts. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Conduct nonjudgmental structured intake and preserve source-faithful reports. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Structure reported belief, symptom, access, memory, dexterity, packaging, and routine barriers. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Match stated barriers to approved non-clinical support options and explain features. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Prepare the barrier, current regimen, and feasible options. | Yes for the actual selected human act | Actual prescribing medical clinician (U.S. prescribing/E-M clinician) or paid contracted pharmacist within scope (External party). The actual paid authorized professional decides any dose, timing, formulation, drug, or regimen change when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Prepare requests, track status, and run approved administrative follow-up. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Configure chosen digital reminders/logs only from current authorized instructions. Physical packaging/setup, supervised administration and professional compatibility are separate branches. | No for the digital act; separate physical/recovery work | No person for digital execution; Philippine L1 support for actual administrative recovery; External party only for separately selected paid physical work. No human for the supported digital act. Actual manual accessibility/setup or physical assistance is separate paid work when performed, never zero-cost by labeling this S. If physical help is included in our promise, its actual qualified paid contractor is costed under O-052; not an S-only furnished service. | |
| 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. | Render approved instructions, adapt explanation, and prompt teach-back. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Schedule conversational follow-up and surface discrepancy/symptom/refusal cues. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Assemble evidence and record the authorized result. | Yes for the actual selected human act | Actual prescribing medical clinician (U.S. prescribing/E-M clinician) or paid contracted pharmacist within scope (External party). The actual paid authorized professional reconciles the regimen and authorizes the updated treatment/instruction when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. |
High-touch recovery after care transitions#
When and useful result. An actual admission/discharge/move and an additional recovery need exist. Required GUIDE transition work continues even without the optional high-touch package. The added result is a requested or selected early recovery conversation with actual barrier resolution; required care coordination and transitional support continues independently.
Prepare once. Current setting/location, discharge sources/dates, current regimen and discrepancies, appointments/pending results, equipment/home-service status, caregiver capacity and specific open promises. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. TR01-02 prepare. TR03-04 are one selected L2 nonclinical recovery conversation, with direct exact U.S. clinical care for interpretation/urgency and TR06 reconciliation. TR07-10 maintain actual logistics and returns, not a second automatic call. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return each actual barrier result, accepting clinician/professional, clinical answer where needed, person-facing instructions and still-open next action. Discharge-to-home, scheduling or a transfer attempt alone does not prove recovery. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Detect connected events, collect location facts, and prepare/schedule early outreach. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Retrieve, organize, source-label, identify gaps, and prepare requests. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Conduct an approved text/voice recovery interview, provide context, and draft documentation. | Yes for the actual selected human act | Puerto Rico GUIDE navigator (Puerto Rico GUIDE navigator). Paid human conducts the substantive nonclinical early recovery conversation. Count the actual shared encounter once; additional incidence/minutes/fees remain O-052. | |
| 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. | Ask approved questions, preserve source-faithful answers, and surface positives immediately. | Yes for the actual selected human act | Puerto Rico GUIDE navigator (Puerto Rico GUIDE navigator) asks only approved questions; actual U.S. clinician handles every positive interpretation (U.S. clinical RN, U.S. prescribing/E-M clinician). Paid human asks the approved health-status questions in that same human recovery event and transfers positives. Count the actual shared encounter once; additional incidence/minutes/fees remain O-052. | |
| 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. | Present reported facts and records. | Yes for the actual selected human act | Actual U.S. RN or medical clinician within authority, or outside emergency/treating endpoint (U.S. clinical RN, U.S. prescribing/E-M clinician, External party). The actual paid authorized professional determines clinical urgency, evaluation, testing, and treatment when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Assemble and compare pre-event, facility, discharge, pharmacy, and home sources. | Yes for the actual selected human act | Actual prescribing medical clinician (U.S. prescribing/E-M clinician) or paid contracted pharmacist within scope (External party). The actual paid authorized professional reconciles post-transition medicines when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Check connected status, remind, prepare status requests, and track dependencies. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Identify gaps, conduct routine barrier-solving dialogue, prepare requests/options, and track resolution. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Present prior choices and conduct an accessible source-labeled preference review. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Maintain open work and conduct routine text/voice follow-up, reminders, and status checks. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. |
Early and recurring future planning#
When and useful result. The beneficiary requests planning, changes a preference/supporter/document or agrees a later review. Decline/defer is honored without affecting GUIDE services. The added result is readiness-sensitive repeated planning and usable documents; required Assessment advance planning and care-plan choice continues independently.
Prepare once. Beneficiary's own words, preferred participants, permission versus decision-specific legal authority, jurisdiction, current documents/effective dates and exact medical/legal question. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. FP01-04 may present approved general education and capture a clear choice digitally. L2 facilitates only a real requested/ambiguous relationship act. FP06's clinical counseling/order differs from state-specific legal advice/execution; FP07 sharing uses its actual release class. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return the chosen/deferred topic, permitted supporters, professional result, current documents/destinations and revocation or conflict. Naming someone does not appoint an agent; a diagnosis or failed explanation is not incapacity. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Present approved plain-language information and record readiness/participants. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Guide reflection and summarize the beneficiary's own words. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Explain approved role categories and capture names/permissions. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. U.S. planning source and limits distinguish medical orders from legal documents; actual state approval is a precondition, not an existing field fact. | Deliver only education already approved for the person's current jurisdiction under O-052 and a current state source; otherwise provide general non-advice education and route the exact legal/medical question. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Match selected professionals, schedule, remind, and prepare document requests. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Prepare history, stated values, questions, and draft documentation. | Yes for the actual selected human act | Actual medical clinician for counseling/capacity/medical orders (U.S. prescribing/E-M clinician); attorney is a paid contracted or outside professional for separate legal advice (External party). The actual paid authorized professional provides individualized clinical counseling, capacity work, and medical orders when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Inventory current documents, identify missing destinations, and prepare authorized distribution. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Schedule review, display current choices, and draft requested changes. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. |
Meaningful activity and social connection#
When and useful result. A person-chosen activity/social goal or access barrier exists; generic enjoyable activity does not require a clinical gate. The added result is a preference-matched activity that the person wants to continue; required Care-plan goals, referral and caregiver activity education continues independently.
Prepare once. Interests/dislikes, desired company, practical access, actual provider/programme offering, relevant current clinical limits and the person's participation/enjoyment report. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. MS01-02/04 collect preference and build rule-constrained options. MS03 is only a real clinical/therapeutic suitability question. MS05-06 coordinate; MS07-08 accept feedback and change ordinary preferences without a clinician blessing. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return attended/not attended, enjoyed/distressed/fatigued/unknown and the person's continue/change/stop choice. Structured therapy is not interchangeable with casual recreation; cited NICE cognitive-stimulation/reminiscence populations are mild-to-moderate. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Guide life-history/preferences and organize the person's words. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Administer approved questions and structure logistical barriers. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Prepare preferences, activity demands, and reported risks. | Yes for the actual selected human act | Actual U.S. clinician or paid contracted OT/PT/psychology/therapy professional for the exact suitability act (U.S. clinical RN, U.S. LCSW/behavioral clinician, U.S. prescribing/E-M clinician, External party). If Proxi sells this as furnished care, the selected Proxi-employed or Proxi-contracted professional determines clinical or therapeutic suitability; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Match preferences/logistics to approved options and draft a schedule. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Search approved resources, compare logistics, register, and remind. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Coordinate transport, accessible format, cost support, timing, and approved alternatives. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Collect attendance, enjoyment, distress, fatigue, and preference feedback. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Suggest preference-consistent alternatives and surface concern cues. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. |
Functional independence and reablement#
When and useful result. The beneficiary chooses a daily-life goal and requests/accepts professional rehabilitation. A full therapy promise needs paid qualified capacity, not only a referral. The added result is carry out and evaluate a personally meaningful rehabilitation goal; required Functional assessment and ADL/IADL caregiver support continues independently.
Prepare once. Goal, reported current task performance/help/errors/environment, current therapy instruction, stage/population fit, professional scope and actual practice/barriers. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. FI01-02 prepare without a default navigator. FI03-04/06/08 are the actual rehabilitation professional's assessment, plan, teaching and revision. FI05/07 coordinate and support current instructions. The cited NICE OT/cognitive-rehabilitation recommendation is mild-to-moderate, not all stages. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return professional baseline/plan, usable strategy, actual practice report and professional continue/change/end result. Coordination-only cannot claim furnished therapy; a reminder or household practice is not reassessment. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Prompt examples and capture the beneficiary's desired result. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Guide a structured report of assistance, errors, environment, timing, and prior help. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Assemble history and observations. | Yes for the actual selected human act | Paid contracted OT or other exact rehabilitation professional (External party). If Proxi sells this as furnished care, a paid contracted professional performs and interprets the functional examination; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Present goals/evidence and draft the selected plan. | Yes for the actual selected human act | Paid contracted OT or other exact rehabilitation professional (External party). If Proxi sells this as furnished care, a paid contracted professional designs the rehabilitation/reablement plan and safety limits; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Prepare referrals/orders, schedule, remind, and track vendors/coverage. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Supply approved prompts and practice reminders. | Yes for the actual selected human act | Paid contracted OT or other exact rehabilitation professional (External party). If Proxi sells this as furnished care, a paid contracted professional demonstrates and corrects the approved rehabilitation strategy; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Remind, log practice, answer bounded setup questions, and surface difficulty. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Summarize reports and measures. | Yes for the actual selected human act | Paid contracted OT or other exact rehabilitation professional (External party). If Proxi sells this as furnished care, a paid contracted professional interprets outcome and revises or ends therapy; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. |
Acute-change, pain, and delirium detection#
When and useful result. A reported acute change/pain concern or a requested reporting/education improvement exists. Existing urgent care is not conditional on buying an enhancement. The added result is better source-faithful reports and accepted human follow-through; required 24/7 access, ongoing reports and clinical response continues independently.
Prepare once. Reported usual observations, new change/onset/source, actual clinical subject/current location, current instructions, recent medicines/transition and actual recipient acceptance. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. AC01/03 collect observations and approved general education, not clinical stability. AC02 provides the existing human access route. AC04/06/07 are protected clinical work; AC05 needs trained human observations and instrument authority alongside clinical assessment. AC09 stops at reported comparison unless the separate professional returns a clinical conclusion. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return actual accepted response, professional disposition/treatment, person-facing instructions and unresolved return. Detection here means a reported change or approved stop cue—not automated diagnosis, camera inference, triage or continuous monitoring. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Record attributed usual observations and deliver approved general change-reporting education; never infer clinical stability or individualized warning thresholds. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Provide text/voice intake, preserve context, and connect immediate human fallback when triggered or requested. | No on the supported digital branch; actual stated exceptions only | No new person for displaying an existing approved route. Actual24/7 first answer is paid Philippine L1 support under Manual14, never an AI exchange, promised synchronous digital monitoring or an extra contact. | |
| 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. | Conduct approved questioning and preserve source/time without diagnosis. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Assemble the report and authorized options. | Yes for the actual selected human act | Actual U.S. RN or medical clinician within authority, or outside emergency endpoint (U.S. clinical RN, U.S. prescribing/E-M clinician, External party). The actual paid authorized professional determines urgency and disposition when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Present configured items and calculate a permitted score. | Yes for the actual selected human act | Actual U.S. RN within scope for administration and actual medical clinician for selection/interpretation when required (U.S. clinical RN, U.S. prescribing/E-M clinician). The actual paid authorized professional performs the observation and clinically selects/interprets the tool when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Assemble observations, records, medicines, and results. | Yes for the actual selected human act | Actual U.S. RN or medical clinician and paid contracted pharmacist only for the exact scoped act (U.S. clinical RN, U.S. prescribing/E-M clinician, External party). The actual paid authorized professional performs history/examination/differential assessment when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Draft communication from the authorized decision and support accessibility. | Yes for the actual selected human act | Treating or Proxi medical clinician authorized for the actual act (U.S. prescribing/E-M clinician); outside pharmacy/provider executes (External party). The actual paid authorized professional selects and explains treatment when this actual act is needed. Record actual event minutes under O-052, reuse an already shared clinical event once, and do not infer a new rate or minute range. | |
| 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. | Schedule, prepare approved requests, remind, and track tests/pharmacy/equipment/follow-up. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| AC09. Recheck and update the baseline | Compare new attributed reports with recorded usual observations. Updating reported facts does not declare a new clinical baseline; a material clinical conclusion needs its own professional return. | NICE recommends repeat pain assessment and continued attention to clinical causes of behavior or distress. | Collect the new report and compare source/time against reported usual observations; clinical baseline/update requires a separate attributable professional result. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. A material clinical baseline question goes directly through Select the professional for this act; this collection never settles it. |
Nutrition, hydration, and swallowing support#
When and useful result. A current eating/drinking difficulty, professional plan or practical access need exists. Current choking/breathing/altered-consciousness reports take the immediate route before routine intake. The added result is implement a professional nutrition/mealtime plan with practical follow-through; required Assessment, referral, caregiver support and clinical response continues independently.
Prepare once. Attributed intake/weight/mealtime reports, current instructions, actual assistance/access, oral/dental or swallowing concern, goals and distinct professional authored components. Preserve speaker/subject, source and as-of time, missing/conflicting facts and actual current instructions; do not gather the same packet twice.
Procedure and branches. NU01-02 collect without diagnosis. NU03 is human emergency connection, not an AI dehydration-severity judgment. NU04 medical, dietetic and dental work remain scoped; NU05 swallowing is SLP work; NU06 keeps each author; NU08 teaching does not change texture, fluid targets or positioning independently. Read each task below for its exact software result and actual paid human entry.
Return and next action. Return actual professional assessment/plan, delivered supplies/services, safe intended-use teaching and reported tolerance/remaining concern. A referral does not mean swallowing assessed; refusal/nonuse/unknown is not failure or reassurance. Record actual performer/content/result/date, permission/release where applicable and the next accepted action. Delivery, acceptance, actual use and later usefulness are distinct.
If unfinished. Apply the owning base SOP for the affected act and its approved due time, attempts and backup; do not invent a new SLA here. Tell the person the actual pending item and next promised update. No response remains unknown; declined/deferred/unavailable/unhelpful are truthful results, not success. A failed urgent connection uses the approved immediate backup/local emergency route, never an AI safe-wait decision. Independent work continues; O-052 must settle extra follow-up cadence/cost before promising it.
| Task | What the step entails | Evidence/value basis | What Proxi can do | Paid Proxi human? | Actual paid act / conditional performer | Review |
|---|---|---|---|---|---|---|
| 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. | Administer approved questions and surface warning cues. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| 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. | Structure food/fluid, timing, positioning, environment, supply, and assistance reports. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. | |
| NU03. Respond to immediate choking or severe dehydration concern | For reported current choking, breathing difficulty, altered consciousness or another approved objective emergency cue, use the immediate human/emergency route. Do not infer dehydration severity or safe waiting. | Swallowing safety and acute hydration risk require prompt qualified response, not routine navigation. | Pass the reported current choking, breathing difficulty, altered consciousness or approved objective stop cue to the immediate route; do not diagnose severe dehydration. | Yes for the actual selected human act | Philippine first-answer support for live connection (Philippine L1 support); actual U.S. clinician or outside emergency endpoint determines response (U.S. clinical RN, U.S. prescribing/E-M clinician, External party). Paid L1 performs only live nonclinical capture/connection inside the existing roster; the authorized clinical or public-safety recipient accepts the live concern and completes the emergency/clinical handoff. Count the same event once; no extra enhanced contact is manufactured. | |
| 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. | Assemble history, trends, medicines, and records. | Yes for the actual selected human act | Actual U.S. RN or medical clinician plus paid contracted dietitian/dentist only for exact scoped work (U.S. clinical RN, U.S. prescribing/E-M clinician, External party). If Proxi sells this as furnished care, the selected Proxi-employed or Proxi-contracted professional performs the clinical nutrition/medical assessment; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Prepare history and observed reports. | Yes for the actual selected human act | Paid contracted speech-language pathologist and treating clinician as applicable (External party, U.S. prescribing/E-M clinician). If Proxi sells this as furnished care, a paid contracted professional performs the swallowing/aspiration-risk assessment; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Format and distribute the authorized plan after release. | Yes for the actual selected human act | Paid contracted dietitian/SLP/dentist and actual medical clinician only for their exact authored components (External party, U.S. prescribing/E-M clinician). If Proxi sells this as furnished care, a paid contracted professional authors the nutrition or swallowing plan; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Match approved resources, schedule/order, remind, and track delivery. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clean work. Philippine L1 support obtains this task's missing administrative fact/transaction on a manual or failed route; Puerto Rico GUIDE navigator resolves only an actual relationship barrier. | |
| 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. | Display approved instructions and reminders. | Yes for the actual selected human act | Paid contracted SLP/dietitian/OT or actual U.S. RN in verified teaching scope (External party, U.S. clinical RN). If Proxi sells this as furnished care, the selected Proxi-employed or Proxi-contracted professional demonstrates and corrects the approved mealtime routine; otherwise Proxi promises preparation, access, and closed-loop coordination only. O-052 must fund capacity/fees; count an already shared professional event once. | |
| 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. | Collect configured observations, schedule follow-up, and surface thresholds. | No on the supported digital branch; actual stated exceptions only | 0 new human minutes on supported clear report/choice. Puerto Rico GUIDE navigator provides requested clarification, relationship help or actual human service; Philippine L1 support captures only otherwise inaccessible administrative facts. |
Requirement, value, and clinical classification#
| Task | GUIDE standing | Customer-value position | Clinical lane | Why |
|---|---|---|---|---|
| LC01. Offer recurring coaching | Caregiver education/support baseline shared; only a distinct additional result is optional | Optional repeat-coaching offer; candidate practical value, not a guaranteed outcome | No clinical judgment | Offering a voluntary coaching relationship is preference and service work. |
| LC02. Choose the immediate coaching goal | Caregiver education/support baseline shared; only a distinct additional result is optional | A new caregiver-chosen practical goal; candidate practical value, not a guaranteed outcome | No clinical judgment | The caregiver chooses the practical result they want. |
| LC03. Understand what happens now | Caregiver education/support baseline shared; only a distinct additional result is optional | Updated context for that chosen goal; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine context collection is delegable; symptoms or safety concerns move to a clinician. |
| LC04. Select an approved coaching lesson | Caregiver education/support baseline shared; only a distinct additional result is optional | A goal-matched approved lesson; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Approved education can be matched routinely unless the reported need is clinical. The digital completion is only the stated factual/approved-content result; any protected conclusion remains separate. |
| LC05. Practice the skill | Caregiver education/support baseline shared; only a distinct additional result is optional | Focused safe rehearsal and correction; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine rehearsal is non-clinical; individualized medical or safety questions escalate. |
| LC06. Agree on one home action | Caregiver education/support baseline shared; only a distinct additional result is optional | One intended home action and help route; candidate practical value, not a guaranteed outcome | Clinical review on trigger | A practical action is delegable when it does not change clinical care. |
| LC07. Check what happened | Caregiver education/support baseline shared; only a distinct additional result is optional | The agreed action's later reported usefulness; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Follow-up is routine until the report contains a new clinical concern. |
| LC08. Adapt, continue, or escalate | Caregiver education/support baseline shared; only a distinct additional result is optional | Targeted additional coaching or actual clinical response; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Coaching may adapt within scope; clinical severity and treatment remain licensed work. |
| BD01. Receive the behavior or distress concern | Assessment and caregiver behavior support baseline shared; only a distinct additional result is optional | A new attributable distress report; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Human intake is routine, while severe distress or danger needs clinical response. |
| BD02. Describe the behavior observably | Assessment and caregiver behavior support baseline shared; only a distinct additional result is optional | Situation-specific observable description; candidate practical value, not a guaranteed outcome | No clinical judgment | Recording observable facts does not assign a diagnosis or cause. |
| BD03. Identify pattern and context | Assessment and caregiver behavior support baseline shared; only a distinct additional result is optional | Updated pattern/context comparison; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Pattern collection is delegable; sudden or medically concerning change escalates. |
| BD04. Assess possible medical causes | Assessment and caregiver behavior support baseline shared; only a distinct additional result is optional | A genuinely new/due medical-cause question; candidate practical value, not a guaranteed outcome | Clinical judgment required | Determining pain, delirium, illness, or medication contribution is clinical assessment. |
| BD05. Assess unmet needs and environmental contributors | Assessment and caregiver behavior support baseline shared; only a distinct additional result is optional | Practical unmet-need facts for this situation; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine needs and environment review is delegable, with clinical exceptions. The digital completion is only the stated factual/approved-content result; any protected conclusion remains separate. |
| BD06. Determine urgency and treatment | Assessment and caregiver behavior support baseline shared; only a distinct additional result is optional | A new/due urgency or treatment decision; candidate practical value, not a guaranteed outcome | Clinical judgment required | Urgency, diagnosis, disposition, and treatment cannot be delegated. |
| BD07. Build the non-drug response plan | Assessment and caregiver behavior support baseline shared; only a distinct additional result is optional | An authorized additional response strategy; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Trained staff may use approved strategies; individualized clinical treatment requires review. |
| BD08. Coach the people who will use the plan | Assessment and caregiver behavior support baseline shared; only a distinct additional result is optional | Focused application of that strategy; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Approved coaching is delegable, while clinical questions return to the professional. |
| BD09. Review outcomes and revise | Assessment and caregiver behavior support baseline shared; only a distinct additional result is optional | Its reported outcome and warranted revision; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine observation supports revision; worsening symptoms or treatment changes are clinical. |
| FL01. Ask about falls and instability | Assessment fall risk and care coordination baseline shared; only a distinct additional result is optional | A justified repeat fall/instability report; candidate practical value, not a guaranteed outcome | 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 | Baseline safety/access interface—no optional activation | None in this row — baseline interface; optional preparedness or follow-through is elsewhere | 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 | Assessment fall risk and care coordination baseline shared; only a distinct additional result is optional | A new/due risk assessment, not duplicate annual work; candidate practical value, not a guaranteed outcome | Clinical judgment required | Examination and interpretation of modifiable risk are licensed work. |
| FL04. Review the home and daily environment | Assessment fall risk and care coordination baseline shared; only a distinct additional result is optional | An additional specific environment review; candidate practical value, not a guaranteed outcome | 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 | Assessment fall risk and care coordination baseline shared; only a distinct additional result is optional | A new medication-contribution question; candidate practical value, not a guaranteed outcome | Clinical judgment required | Medication contribution and change decisions require a pharmacist or prescriber. |
| FL06. Select the fall-reduction interventions | Assessment fall risk and care coordination baseline shared; only a distinct additional result is optional | Selection for the additional assessed need; candidate practical value, not a guaranteed outcome | Clinical judgment required | Treatment and intervention suitability follow professional assessment. |
| FL07. Arrange the selected services and equipment | Assessment fall risk and care coordination baseline shared; only a distinct additional result is optional | Unfinished selected intervention access; candidate practical value, not a guaranteed outcome | No clinical judgment | Scheduling and obtaining already selected supports are logistical. |
| FL08. Teach and implement the approved plan | Assessment fall risk and care coordination baseline shared; only a distinct additional result is optional | Actual additional device/technique training; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Approved teaching is delegable; individualized correction and new symptoms escalate. |
| FL09. Follow up after intervention or another fall | Assessment fall risk and care coordination baseline shared; only a distinct additional result is optional | Outcome/barrier follow-through or new-fall response; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Completion tracking is routine; another fall or functional change requires reassessment. |
| WN01. Ask about wandering and getting-lost signs | Assessment wandering safety and caregiver training baseline shared; only a distinct additional result is optional | Updated incident/sign report; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Structured collection is delegable; new change or danger triggers review. |
| WN02. Act when the person is currently missing | Baseline safety/access interface—no optional activation | None in this row — baseline interface; optional preparedness or follow-through is elsewhere | 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 | Assessment wandering safety and caregiver training baseline shared; only a distinct additional result is optional | A new/due cause or restriction question; candidate practical value, not a guaranteed outcome | Clinical judgment required | Cause, risk, and restrictions require clinical or safeguarding judgment. |
| WN04. Map patterns, triggers, and likely destinations | Assessment wandering safety and caregiver training baseline shared; only a distinct additional result is optional | A current location/pattern map; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Pattern collection is routine, with clinical review for sudden or unsafe change. |
| WN05. Build a prevention routine | Assessment wandering safety and caregiver training baseline shared; only a distinct additional result is optional | A person-chosen nonclinical prevention routine; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine supports can be planned non-clinically; individualized restrictions require review. |
| WN06. Make the home safer | Assessment wandering safety and caregiver training baseline shared; only a distinct additional result is optional | A specific qualified safety/egress intervention; candidate practical value, not a guaranteed outcome | Clinical review on trigger | General safeguards are practical; restraint, egress, and individualized risk need qualified review. |
| WN07. Arrange identification and location supports | Assessment wandering safety and caregiver training baseline shared; only a distinct additional result is optional | Selected identification/location support; candidate practical value, not a guaranteed outcome | No clinical judgment | The person chooses among identification and notification options. |
| WN08. Create the missing-person response plan | Assessment wandering safety and caregiver training baseline shared; only a distinct additional result is optional | An accessible current response packet; candidate practical value, not a guaranteed outcome | No clinical judgment | Compiling current facts and contacts is preparedness work. |
| WN09. Rehearse the plan | Assessment wandering safety and caregiver training baseline shared; only a distinct additional result is optional | Focused safe human rehearsal; candidate practical value, not a guaranteed outcome | No clinical judgment | Practice tests understanding without making a clinical decision. |
| WN10. Review after an incident or meaningful change | Assessment wandering safety and caregiver training baseline shared; only a distinct additional result is optional | Incident learning plus separately needed reassessment; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Operational lessons are delegable; changed risk or cause requires qualified reassessment. |
| SV01. Ask about sensory function and devices | Assessment hearing referral and accessible service delivery baseline shared; only a distinct additional result is optional | Current sensory/device difficulty report; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine questions are delegable; new symptoms trigger professional review. |
| SV02. Verify prior recommendations and follow-up | Assessment hearing referral and accessible service delivery baseline shared; only a distinct additional result is optional | Close an unfinished recommendation loop; candidate practical value, not a guaranteed outcome | No clinical judgment | Record and referral status verification is factual. |
| SV03. Perform sensory assessment and treatment | Assessment hearing referral and accessible service delivery baseline shared; only a distinct additional result is optional | New/due sensory professional care; candidate practical value, not a guaranteed outcome | Clinical judgment required | Diagnosis, prescribing, fitting decisions, and treatment stay with licensed professionals. |
| SV04. Arrange appointments and access | Assessment hearing referral and accessible service delivery baseline shared; only a distinct additional result is optional | Resolve an actual appointment/access barrier; candidate practical value, not a guaranteed outcome | No clinical judgment | Scheduling and barrier resolution implement an existing referral. |
| SV05. Obtain the prescribed device or correction | Assessment hearing referral and accessible service delivery baseline shared; only a distinct additional result is optional | Obtain/repair a specifically selected support; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Procurement is logistical; professional fitting or intolerance requires review. |
| SV06. Establish the daily device routine | Assessment hearing referral and accessible service delivery baseline shared; only a distinct additional result is optional | Make its approved daily routine usable; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine maintenance is non-clinical; fit, pain, or performance problems return to the provider. |
| SV07. Adapt all service communication | Baseline safety/access interface—no optional activation | None in this row — baseline interface; optional preparedness or follow-through is elsewhere | No clinical judgment | Applying known communication preferences is not medical interpretation. |
| SV08. Check whether correction helped | Assessment hearing referral and accessible service delivery baseline shared; only a distinct additional result is optional | The person's later usability/tolerance report; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Reported usability is routine; persistent or worsening impairment needs reassessment. |
| MU01. Confirm the approved regimen before support | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | Reuse the actual approved regimen; no duplicate review; candidate practical value, not a guaranteed outcome | 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 | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | A new attributed actual-use report; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Report collection is delegable; discrepancies require clinical review. |
| MU03. Identify the specific adherence barrier | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | A specific practical barrier report; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Practical barriers are routine; symptoms and treatment concerns are clinical. |
| MU04. Let the beneficiary choose feasible support | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | Person-selected permitted support; candidate practical value, not a guaranteed outcome | 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 | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | A genuinely needed authorized regimen change; candidate practical value, not a guaranteed outcome | Clinical judgment required | Dose, timing, formulation, and treatment changes require prescribing authority. |
| MU06. Resolve supply, packaging, and delivery barriers | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | Close a specific supply/packaging barrier; candidate practical value, not a guaranteed outcome | No clinical judgment | Administrative access work implements an already approved regimen. |
| MU07. Set up the selected reminder or organization support | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | Chosen digital setup or separately actual physical help; candidate practical value, not a guaranteed outcome | No clinical judgment | Setup follows the approved schedule without changing treatment. |
| MU08. Teach back the approved schedule | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | Faithful approved explanation/application support; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Approved instructions may be reinforced; clinical questions escalate. |
| MU09. Monitor use and new concerns | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | Reported usability and new concerns; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine observation is delegable; symptoms, refusal implications, and discrepancies are clinical. |
| MU10. Clinically respond and update the approved plan | Medication management and caregiver instruction baseline shared; only a distinct additional result is optional | A new/due protected instruction or treatment result; candidate practical value, not a guaranteed outcome | Clinical judgment required | Reconciliation and treatment change require a prescriber. |
| TR01. Detect the transition and reach the dyad | Care coordination and transitional support baseline shared; only a distinct additional result is optional | Identify the actual transition/extra recovery need; candidate practical value, not a guaranteed outcome | No clinical judgment | Event detection and outreach are factual and logistical. |
| TR02. Obtain the discharge and transfer information | Care coordination and transitional support baseline shared; only a distinct additional result is optional | Retrieve missing relevant transfer facts; candidate practical value, not a guaranteed outcome | No clinical judgment | Record retrieval does not interpret conflicting instructions. |
| TR03. Conduct the early recovery call | Care coordination and transitional support baseline shared; only a distinct additional result is optional | The selected additional nonclinical recovery conversation; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine human follow-up is delegable with clinical backup for concerns. |
| TR04. Check health status and warning signs | Care coordination and transitional support baseline shared; only a distinct additional result is optional | Its reported status, not clinical interpretation; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Approved questions may be asked by trained staff; positives require interpretation. |
| TR05. Determine the clinical response | Care coordination and transitional support baseline shared; only a distinct additional result is optional | A new/due protected recovery decision; candidate practical value, not a guaranteed outcome | Clinical judgment required | Symptom urgency, diagnosis, and disposition are clinical. |
| TR06. Reconcile post-transition medicines | Care coordination and transitional support baseline shared; only a distinct additional result is optional | A genuinely due reconciliation, counted once; candidate practical value, not a guaranteed outcome | Clinical judgment required | Medication reconciliation and final regimen decisions require prescribing authority. |
| TR07. Verify appointments, equipment, and home services | Care coordination and transitional support baseline shared; only a distinct additional result is optional | Close unfinished appointment/equipment/service facts; candidate practical value, not a guaranteed outcome | No clinical judgment | Verification and administrative follow-through are factual. |
| TR08. Resolve practical and communication gaps | Care coordination and transitional support baseline shared; only a distinct additional result is optional | Resolve a specific recovery barrier; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine barriers are navigational; conflicting clinical instructions escalate. |
| TR09. Review needs, wishes, and plans after the transition | Care coordination and transitional support baseline shared; only a distinct additional result is optional | An actual changed preference/support need; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Preference review is non-clinical; clinical plan changes require a clinician. |
| TR10. Continue recovery follow-up until the handoff works | Care coordination and transitional support baseline shared; only a distinct additional result is optional | Keep an actual unresolved promise moving; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Tracking is routine; unresolved clinical issues remain clinician-owned. |
| FP01. Offer planning without pressure | Assessment advance planning and care-plan choice baseline shared; only a distinct additional result is optional | Optional readiness-sensitive planning offer; candidate practical value, not a guaranteed outcome | No clinical judgment | Readiness and participation are beneficiary choices. |
| FP02. Elicit goals, values, and future preferences | Assessment advance planning and care-plan choice baseline shared; only a distinct additional result is optional | Additional beneficiary-owned values reflection; candidate practical value, not a guaranteed outcome | No clinical judgment | The beneficiary states their own values and preferences. |
| FP03. Identify trusted decision supporters | Assessment advance planning and care-plan choice baseline shared; only a distinct additional result is optional | Current preferred supporters/permissions; candidate practical value, not a guaranteed outcome | No clinical judgment | Naming preferred supporters is a personal choice, not a medical decision. |
| FP04. Explain planning options and documents | Assessment advance planning and care-plan choice baseline shared; only a distinct additional result is optional | Approved general planning education; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Approved general education is delegable; medical and legal advice require professionals. |
| FP05. Arrange professional planning conversations | Assessment advance planning and care-plan choice baseline shared; only a distinct additional result is optional | The person's chosen professional conversation; candidate practical value, not a guaranteed outcome | No clinical judgment | Referral and scheduling do not provide the professional advice. |
| FP06. Complete clinical counseling and medical orders | Assessment advance planning and care-plan choice baseline shared; only a distinct additional result is optional | Actual individualized counseling/order, not legal execution; candidate practical value, not a guaranteed outcome | Clinical judgment required | Capacity, individualized medical counseling, and medical orders are nondelegable. |
| FP07. Organize and share completed documents | Assessment advance planning and care-plan choice baseline shared; only a distinct additional result is optional | Find/share current documents through permitted routes; candidate practical value, not a guaranteed outcome | No clinical judgment | Authorized document organization and distribution are administrative. |
| FP08. Revisit the plan after change and at agreed intervals | Assessment advance planning and care-plan choice baseline shared; only a distinct additional result is optional | Requested/agreed changed-wishes review; candidate practical value, not a guaranteed outcome | 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 | Care-plan goals, referral and caregiver activity education baseline shared; only a distinct additional result is optional | Current person-owned identity/interests; candidate practical value, not a guaranteed outcome | No clinical judgment | The person supplies their own preferences and life history. |
| MS02. Understand current connection and barriers | Care-plan goals, referral and caregiver activity education baseline shared; only a distinct additional result is optional | A specific connection/access barrier; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Practical barriers are navigational; depression, distress, or safety concerns escalate. |
| MS03. Assess clinical or therapeutic suitability when needed | Care-plan goals, referral and caregiver activity education baseline shared; only a distinct additional result is optional | Only an actual suitability/therapy question; candidate practical value, not a guaranteed outcome | Clinical judgment required | Individualized safety and therapy suitability require qualified assessment. |
| MS04. Build a small, personalized activity plan | Care-plan goals, referral and caregiver activity education baseline shared; only a distinct additional result is optional | A person-chosen practical activity schedule; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Preference matching is routine when no clinical safety issue is present. |
| MS05. Connect to suitable people and programs | Care-plan goals, referral and caregiver activity education baseline shared; only a distinct additional result is optional | Close the selected programme connection; candidate practical value, not a guaranteed outcome | No clinical judgment | Connection follows the person's choice and any completed suitability review. |
| MS06. Remove practical participation barriers | Care-plan goals, referral and caregiver activity education baseline shared; only a distinct additional result is optional | Resolve actual participation logistics; candidate practical value, not a guaranteed outcome | No clinical judgment | Transport, format, cost, and accompaniment are logistical. |
| MS07. Check actual participation and experience | Care-plan goals, referral and caregiver activity education baseline shared; only a distinct additional result is optional | Person-owned enjoyment and continue/stop result; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Feedback collection is routine; distress or functional change triggers review. |
| MS08. Adapt or clinically reassess the activity plan | Care-plan goals, referral and caregiver activity education baseline shared; only a distinct additional result is optional | Ordinary adaptation or separately needed reassessment; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine preferences can be changed non-clinically; safety and therapy changes require review. |
| FI01. Choose a beneficiary-defined functional goal | Functional assessment and ADL/IADL caregiver support baseline shared; only a distinct additional result is optional | A personally meaningful rehabilitation goal; candidate practical value, not a guaranteed outcome | No clinical judgment | The beneficiary chooses the daily-life result that matters. |
| FI02. Describe current performance and context | Functional assessment and ADL/IADL caregiver support baseline shared; only a distinct additional result is optional | Goal-specific current performance/context; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Observation can be collected routinely; safety or clinical causes trigger review. |
| FI03. Perform the functional assessment | Functional assessment and ADL/IADL caregiver support baseline shared; only a distinct additional result is optional | An additional accepted professional assessment; candidate practical value, not a guaranteed outcome | Clinical judgment required | Functional examination and interpretation require a qualified therapist or clinician. |
| FI04. Create the rehabilitation or reablement plan | Functional assessment and ADL/IADL caregiver support baseline shared; only a distinct additional result is optional | The actual professional goal-based plan; candidate practical value, not a guaranteed outcome | Clinical judgment required | Therapy design and safety limits are nondelegable professional work. |
| FI05. Arrange therapy, devices, and environmental support | Functional assessment and ADL/IADL caregiver support baseline shared; only a distinct additional result is optional | Close that plan's therapy/device access; candidate practical value, not a guaranteed outcome | No clinical judgment | Coordination implements a professional plan. |
| FI06. Teach the approved strategy | Functional assessment and ADL/IADL caregiver support baseline shared; only a distinct additional result is optional | Professional teaching of the selected technique; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Approved practice support is delegable; individualized correction remains professional. |
| FI07. Support practice and remove barriers | Functional assessment and ADL/IADL caregiver support baseline shared; only a distinct additional result is optional | Support actual practice without altering therapy; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine reminders are delegable; difficulty or decline returns to the therapist. |
| FI08. Reassess progress and revise the plan | Functional assessment and ADL/IADL caregiver support baseline shared; only a distinct additional result is optional | A genuinely due professional outcome/revision; candidate practical value, not a guaranteed outcome | Clinical judgment required | Functional outcome interpretation and therapy revision require a qualified professional. |
| AC01. Establish and teach the observable baseline | 24/7 access, ongoing reports and clinical response baseline shared; only a distinct additional result is optional | Attributed usual observations/general education; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine observations are delegable; individualized medical warnings require clinician input. The digital completion is only the stated factual/approved-content result; any protected conclusion remains separate. |
| AC02. Provide an easy human reporting route | Baseline safety/access interface—no optional activation | None in this row — baseline interface; optional preparedness or follow-through is elsewhere | No clinical judgment | Access instructions and connection are non-clinical. |
| AC03. Capture the new observation | 24/7 access, ongoing reports and clinical response baseline shared; only a distinct additional result is optional | A new source-faithful change report; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Fact collection is delegable; reported danger or symptoms trigger clinical review. |
| AC04. Determine immediate urgency and disposition | 24/7 access, ongoing reports and clinical response baseline shared; only a distinct additional result is optional | Current protected disposition; not an optional add-on; candidate practical value, not a guaranteed outcome | Clinical judgment required | Individualized urgency and disposition are nondelegable. |
| AC05. Administer an appropriate observational pain screen | 24/7 access, ongoing reports and clinical response baseline shared; only a distinct additional result is optional | Indicated trained pain observation alongside assessment; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Configured administration may be delegated; tool choice and interpretation are clinical. |
| AC06. Assess pain, delirium, illness, and medication causes | 24/7 access, ongoing reports and clinical response baseline shared; only a distinct additional result is optional | Actual clinical cause assessment; candidate practical value, not a guaranteed outcome | Clinical judgment required | Differential assessment, examination, and diagnosis are licensed work. |
| AC07. Decide and communicate treatment | 24/7 access, ongoing reports and clinical response baseline shared; only a distinct additional result is optional | Actual authorized treatment/result; candidate practical value, not a guaranteed outcome | Clinical judgment required | Treatment selection and individualized counseling require the treating clinician. |
| AC08. Carry out the coordination around the clinical plan | 24/7 access, ongoing reports and clinical response baseline shared; only a distinct additional result is optional | Close the surrounding agreed care actions; candidate practical value, not a guaranteed outcome | No clinical judgment | Scheduling and administrative execution follow the authorized plan. |
| AC09. Recheck and update the baseline | 24/7 access, ongoing reports and clinical response baseline shared; only a distinct additional result is optional | Reported follow-through; clinical update separately authored; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Follow-up observations are delegable; persistent change needs clinical interpretation. The digital completion is only the stated factual/approved-content result; any protected conclusion remains separate. |
| NU01. Ask about eating, drinking, and mealtime difficulty | Assessment, referral, caregiver support and clinical response baseline shared; only a distinct additional result is optional | Updated eating/drinking concern report; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine questions are delegable; positive swallowing or nutrition concerns escalate. |
| NU02. Describe the pattern and practical barriers | Assessment, referral, caregiver support and clinical response baseline shared; only a distinct additional result is optional | Specific practical mealtime context; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Practical context is delegable; clinical signs require professional review. |
| NU03. Respond to immediate choking or severe dehydration concern | Baseline safety/access interface—no optional activation | None in this row — baseline interface; optional preparedness or follow-through is elsewhere | 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 | Assessment, referral, caregiver support and clinical response baseline shared; only a distinct additional result is optional | Actual medical/dietetic/dental assessment; candidate practical value, not a guaranteed outcome | Clinical judgment required | Cause, diagnosis, testing, and treatment are clinical. |
| NU05. Perform swallowing assessment | Assessment, referral, caregiver support and clinical response baseline shared; only a distinct additional result is optional | Actual indicated swallowing assessment; candidate practical value, not a guaranteed outcome | Clinical judgment required | Aspiration risk and swallowing recommendations require a speech-language pathologist or clinician. |
| NU06. Create the approved nutrition or swallowing plan | Assessment, referral, caregiver support and clinical response baseline shared; only a distinct additional result is optional | Distinct authorized nutrition/swallowing components; candidate practical value, not a guaranteed outcome | Clinical judgment required | Nutrition treatment, texture, and swallowing-safety plans require qualified professionals. |
| NU07. Resolve food, supply, and appointment barriers | Assessment, referral, caregiver support and clinical response baseline shared; only a distinct additional result is optional | Close an actual food/supply/visit barrier; candidate practical value, not a guaranteed outcome | No clinical judgment | Resource and appointment coordination are logistical. |
| NU08. Teach and support the approved mealtime routine | Assessment, referral, caregiver support and clinical response baseline shared; only a distinct additional result is optional | Safe actual application of the current plan; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Approved strategies may be reinforced; individualized changes return to professionals. |
| NU09. Monitor intake, comfort, weight, and new warning signs | Assessment, referral, caregiver support and clinical response baseline shared; only a distinct additional result is optional | Reported intake/tolerance plus indicated reassessment; candidate practical value, not a guaranteed outcome | Clinical review on trigger | Routine observations are delegable; deterioration and warning signs require clinical review. |