Status: Working business classification for the eight in-scope GUIDE services
Date: 2026-07-11
Scope: Comprehensive assessment, care planning, 24/7 access, ongoing monitoring and support, care coordination and transitions, referrals and services, medication management, and caregiver education and support. GUIDE respite is excluded from Proxi's service scope.
The answer in plain language#
Proxi has three separate questions to answer for every piece of work:
- What must be done to participate in GUIDE? The answer includes both care-delivery work and program-operating work such as consent, alignment, assessment submission, staffing, navigator training, and reporting.
- What should Proxi do because it creates real value? Some of the best customer value comes from performing a required service unusually well: proactively, personally, and with closed-loop follow-through. Other value comes from evidence-backed services that go beyond the public GUIDE minimum.
- Where is clinical judgment non-delegable? Diagnosis, clinical interpretation, risk and urgency decisions, treatment decisions, prescribing, medication reconciliation, and other medical judgments stay with an appropriately licensed clinician. Most collection, coordination, education, tracking, and follow-through can be performed by trained non-clinical people and supported by Proxi, with clinical review when a defined concern appears.
These are independent questions. A task can be a GUIDE requirement and a major customer-value opportunity. A task can require a human without requiring clinical judgment. A task can be substantially automated while its final clinical judgment remains with a clinician.
The same separation applies at the beneficiary-month level. Proxi's promise to furnish the full non-respite GUIDE package means maintaining and owning every applicable service capability; it does not mean every beneficiary must receive all eight service domains every month. Under the current public GUIDE Payment Methodology Paper §3.1, a DCMP month needs at least one actually furnished non-respite GUIDE care-delivery service plus compliance with the beneficiary's tier-specific contact cadence. There is no public minimum duration or minimum number of distinct service domains.
What can and cannot be called a confirmed GUIDE requirement#
The current public CMS materials do not contain the participant's executed Amended and Restated Participation Agreement or its contractual Appendix D. The 2026 Payment Methodology Paper says it must be read with that agreement and GUIDE Connect guidance. The 2026 Performance Measurement Manual calls its care-delivery table supportive rather than exhaustive or a formal protocol and directs participants to Participation Agreement Appendix D.
Accordingly, this project will use the following source order:
- The executed current Participation Agreement, amendments, and contractual Appendix D.
- Current CMS operating guidance issued under that agreement, including the 2026 Payment Methodology Paper.
- Current subject-specific CMS manuals and instructions, including the 2026 Performance Measurement Manual and current PAAF instructions.
- The public GUIDE RFA, especially Appendix B, as the public care-delivery baseline.
- Current CMS FAQs and model-page clarifications.
Until the participant documents in item 1 are available, every public-source requirement determination remains a working determination pending Participation Agreement verification. This is a document dependency, not a reason to stop defining the work.
The three business classifications#
GUIDE standing#
| Label | Meaning |
|---|---|
| Public 2026 requirement | A current public CMS source directly requires the action, result, role, timing, submission, or prohibition. It still requires comparison with the executed Participation Agreement. |
| Public RFA care-delivery requirement | The public RFA directly requires the care-delivery action or result. Treat it as the public baseline while checking the current Participation Agreement for additions or changes. |
| Necessary delivery work | CMS requires the result, but does not prescribe this exact enabling step. Removing the step from Proxi's chosen operating method would make reliable delivery or proof of the required result unlikely. |
| Beyond the public GUIDE minimum | A credible path can meet the identified public GUIDE duties without this work. The work may still be required by other law, professional standards, payer contracts, or Proxi policy. |
The test is the action, not the citation count. A CMS statement that an organization “may” take an optional route does not make that route mandatory. A performance measure does not by itself become an individual treatment requirement.
Customer-value position#
| Label | Meaning |
|---|---|
| Compliance infrastructure | Necessary for participation or proof, but not usually experienced by the beneficiary or caregiver as service value. |
| Core customer value | Work the beneficiary or caregiver directly experiences and that materially affects safety, confidence, burden, continuity, or quality of life. It may also be required by GUIDE. |
| Value through better execution | The underlying service is required, while Proxi differentiates it through personalization, anticipation, speed, usability, and verified closed-loop follow-through. |
| Additional evidence-backed value | A service beyond the identified public GUIDE minimum that is supported by dementia-care evidence or authoritative guidance and is worth considering as part of the Proxi offer. |
Clinical lane#
| Label | Meaning |
|---|---|
| Clinical judgment required | The task contains diagnosis, examination, clinical interpretation, individualized risk or urgency judgment, treatment, medication reconciliation, prescribing, deprescribing, or another decision restricted by license and scope. The judgment cannot be delegated to Proxi or an unlicensed worker. Collection and preparation around the judgment may still be delegated. |
| Clinical review on trigger | A trained non-clinical person may perform the routine work. A defined completion point or finding—such as a completed medication-source comparison, positive screen, new symptom, safety concern, medical question, contradiction, material change, or unresolved uncertainty—moves the work to an appropriately licensed clinician. |
| No clinical judgment | The work is factual, logistical, administrative, educational from approved material, preference-based, or coordination-focused. It may be delegated or automated when privacy, authorization, competence, and the GUIDE human-role requirements permit. |
“No clinical judgment” does not mean “no person.” CMS requires the care navigator to be an individual rather than artificial intelligence, makes the navigator the primary contact, and requires human support for 24/7 access. Consent, beneficiary choice, sensitive communication, and relationship work may also require a person even when they do not require a clinician.
This split follows the public GUIDE RFA care-team provisions, which permit a trained non-practitioner care navigator but direct non-clinical navigators to consult clinical team members on medical or complex issues, and the ANA/NCSBN National Guidelines for Nursing Delegation, which state that clinical reasoning, nursing judgment, and critical decision-making cannot be delegated.
The non-delegable clinical core#
The following judgment must stay with an appropriately licensed professional acting within scope:
- Confirming or changing a dementia diagnosis and interpreting diagnostic uncertainty.
- Performing and interpreting a cognition-focused clinical examination.
- Determining medical-decision-making complexity and making clinical conclusions from the comprehensive assessment.
- Selecting and clinically interpreting dementia staging, behavioral-health, functional, or other clinical instruments when interpretation affects care.
- Determining the severity, urgency, or disposition of new symptoms, possible delirium, suicidal thoughts, falls, driving concerns, wandering, abuse or neglect concerns, swallowing problems, pain, or other safety findings.
- Deciding whether a referral, test, treatment, or change in treatment is clinically appropriate and how urgent it is.
- Performing medication reconciliation; assessing indications, interactions, duplications, contraindications, side effects, and appropriateness; and prescribing or deprescribing.
- Establishing or changing clinical goals, medical interventions, and clinician-owned portions of the care plan.
- Creating or signing medical orders, including any order component of POLST or an equivalent state form.
The surrounding work does not all need a clinician. Proxi and trained staff can gather source information, administer permitted structured questions, calculate configured scores, identify missing or conflicting facts, prepare summaries, schedule encounters, obtain records, deliver approved education, track follow-up, and document the clinician's decision.
Safety conditions for delegated work#
Delegation is safe only if it does not turn the absence of an alert into an unsupported clinical conclusion.
- No trigger is not a finding of stability. A trained navigator may report that no configured concern was identified. The navigator may not conclude that the beneficiary is clinically stable or that no clinical action is needed.
- A negative self-report is not always sufficient. Dementia can reduce insight into functional loss or risk. ADL, IADL, behavior, medication, and safety information should be corroborated with an involved caregiver, available records, or qualified observation when those sources are available and authorized. Missing corroboration remains visible rather than being converted into a clean negative.
- Clinical assessment cannot be purely exception-driven. The required initial and annual comprehensive assessments provide scheduled clinical baselines. The clinical team also decides whether an earlier reassessment or other planned clinical review is appropriate; Proxi and the navigator do not wait for an algorithmic alert when professional follow-up is already due.
- Uncertainty is itself a trigger. A contradiction, incomplete source, unexplained change, unreliable history, or concern that does not fit a routine category is sent for qualified review instead of being resolved by a non-clinical worker.
- Open-ended observation has a boundary. Navigators can collect what a person reports, use approved structured prompts, and describe observable facts. They do not convert subtle symptoms or implicit needs into a clinical conclusion; they send the original observation to the appropriate clinician.
Current result across the full task inventory#
The business inventory now contains 603 literal tasks. These are task-row counts, not estimates of labor hours, case volume, or staffing ratios.
| Body of work | Tasks | Public 2026 requirement | Public RFA requirement | Necessary delivery work | Beyond public minimum | Clinical judgment | Clinical review on trigger | No clinical judgment | Review |
|---|---|---|---|---|---|---|---|---|---|
| Eight GUIDE care-service tables | 359 | 1 | 148 | 198 | 12 | 25 | 146 | 188 | |
| GUIDE program operations outside the services | 138 | 79 | 26 | 29 | 4 | 5 | 43 | 90 | |
| Candidate enhanced dementia-care services | 106 | 0 | 0 | 0 | 106 | 22 | 55 | 29 | |
| Combined inventory | 603 | 80 | 174 | 227 | 122 | 52 | 244 | 307 |
The working public-source operating floor is 481 tasks: 80 direct current-public 2026 requirements, 174 direct public-RFA requirements awaiting current Participation Agreement verification, and 227 necessary steps for reliably delivering or proving those results. The other 122 rows consist of 16 optional or beyond-minimum rows already present in the public-source operating inventory and 106 candidate enhanced-service tasks.
The first complete classification pass covers all 359 tasks in the eight service tables:
| Question | Result | Review |
|---|---|---|
| How many task rows contain non-delegable clinical judgment? | 25 of 359 (7%) | |
| How many can be done routinely by trained non-clinical staff or Proxi but require clinical review at a defined handoff or finding? | 146 of 359 (41%) | |
| How many contain no clinical judgment? | 188 of 359 (52%) | |
| How many are direct public RFA care-delivery requirements? | 148 | |
| How many are direct current-public 2026 requirements represented inside the service rows? | 1; most current 2026 program-operating duties sit outside these eight tables and are listed below. | |
| How many are necessary enabling steps for reliable delivery of a required result? | 198 | |
| How many are beyond the identified public GUIDE minimum within the existing service rows? | 12 |
The 25 task rows with an irreducible clinical judgment component are concentrated rather than spread evenly:
| Service | Non-delegable clinical work represented in its task rows | Count | Review |
|---|---|---|---|
| Comprehensive assessment | Cognition-focused examination; medical-decision-making complexity; clinical staging interpretation; medication reconciliation; driving and fall-risk judgment; POLST medical orders; needed clinical coordination; clinical synthesis; decision for additional diagnostic evaluation; explanation of clinical findings and uncertainty | 11 | |
| Person-centered care plan | Selection of clinical care options; diagnosis, treatment, medication, and other required clinical decisions | 2 | |
| Care coordination and transitions | Interpretation of outside-PCP information; decision that a specialist referral is clinically appropriate; clinical consultation with an actively co-managing PCP; resolution of conflicting recommendations; interpretation of returned transition recommendations | 5 | |
| Medication management | Clinical reconciliation; prescribing; deprescribing; identifying the clinically relevant provider for agreement; resolving a modified or declined recommendation; issuing the lawful order; selecting a clinical alternative when access fails | 7 | |
| 24/7 access, ongoing monitoring, community referrals, and caregiver support | No routine row always requires clinical judgment. These services are human-led and contain defined clinical-review triggers when symptoms, safety concerns, medical questions, contradictions, or uncertainty appear. | 0 |
The customer-value classification of the same 359 rows is 196 core customer-value tasks, 104 opportunities to differentiate through better execution, 52 compliance-infrastructure tasks, and 7 additional value tasks already present in the public RFA's optional routes.
The evidence-backed candidate services have now been decomposed separately into 106 additional work steps in 19_Proxi_Enhanced_Dementia_Care_Tasks.md: 22 contain clinical judgment, 55 are routine non-clinical work with a clinical-review trigger, and 29 contain no clinical judgment. All 106 remain candidate Proxi services beyond the identified public GUIDE minimum until the business chooses which ones belong in the offer.
GUIDE operating work outside the eight service tables#
The existing 359 tasks describe the eight in-scope care services. They do not yet constitute the entire GUIDE operating obligation. At minimum, the current public-source operating picture also includes the following work.
| Program work | Public-source standing | What must actually happen | Clinical lane | Primary human owner | Review |
|---|---|---|---|---|---|
| Explain exclusive GUIDE care-delivery alignment and obtain consent | Public 2026 requirement | Before the initial comprehensive assessment, discuss receipt of GUIDE care-delivery services exclusively from the participant; obtain patient and/or caregiver consent; document the discussion, consent, or refusal in the medical record. Clinical freedom of choice for other services remains intact. | No clinical judgment | Trained enrollment or care-team staff; patient and/or caregiver makes the choice. | |
| Confirm potential eligibility before alignment | Public 2026 requirement | Confirm the known eligibility facts and identify facts CMS must validate; do not represent a potentially eligible person as aligned before CMS confirms. | Clinical review on trigger | Enrollment staff or data custodian; clinician for diagnosis-related facts. | |
| Collect the current assessment and alignment data set | Public 2026 requirement | During the initial assessment collect the required patient, clinician, caregiver, residence, dementia-stage, PROMIS v1.2 Global Health, and when applicable ZBI-22 information using the current PAAF requirements. | Mixed: clinical judgment for clinical findings; no clinical judgment for factual capture | Assessment team; dementia-proficient clinician; data custodian. | |
| Complete the dementia diagnosis attestation | Public 2026 requirement | A dementia-proficient practitioner on the approved roster attests based on the comprehensive assessment or an acceptable written diagnosis from another Medicare-enrolled practitioner; record the attestation in the PAAF. | Clinical judgment required | Dementia-proficient practitioner on the participant roster. | |
| Prepare and submit the initial PAAF | Public 2026 requirement | The participant's data custodian enters the required information and submits the completed PAAF through an approved CMS route within 60 days of the dementia-staging assessment date. | Clinical review on trigger | Data custodian; clinical owner resolves clinical contradictions. | |
| Receive and act on CMS eligibility and alignment results | Public 2026 requirement | Retrieve the real-time preliminary response for care planning, then use the final Beneficiary Alignment Report as the confirmed alignment source and first-month billing basis; distinguish aligned, ineligible, and pending results and correct permitted errors. | No clinical judgment for result handling; clinical review if a diagnosis fact is disputed | Data custodian and program operations. | |
| Notify the patient of alignment status | Public 2026 requirement | Give each eligible, aligned patient written notice using the CMS alignment template within 45 days after the final Beneficiary Alignment Report decision, and retain proof that the notice was provided. | No clinical judgment | Enrollment or program operations staff. | |
| Conduct and submit the annual assessment | Public 2026 requirement | Start the annual assessment between days 306 and 425 after the previous assessment and submit it by the earlier of 60 days after it begins or day 425; use the current PAAF and submission route. | Mixed, following the assessment task boundaries | Assessment team and data custodian. | |
| Submit qualifying reassessment changes | Public 2026 requirement | Submit changes that affect tiering, payment, or eligibility according to the current cadence: residence-type changes may be accepted every 30 days; dementia severity and caregiver-status or burden changes every 180 days. Reassessment does not replace the annual assessment. | Clinical judgment for dementia severity; otherwise clinical review on trigger | Care team and data custodian. | |
| Maintain the required interdisciplinary care team | Public 2026 core; RFA detail pending Participation Agreement check | Keep at least a human care navigator and a CMS-approved dementia-proficient clinician eligible for Part B E/M services. The public RFA additionally requires a physician medical director when the dementia-proficient clinician is not a physician; verify that detail against the current agreement. | Mixed | GUIDE program leadership and clinical leadership. | |
| Train every care navigator | Public RFA care-delivery requirement; current particulars pending Participation Agreement check | The public RFA baseline is at least 20 initial hours, including at least 10 didactic and 10 live experiential hours; a comprehension assessment; at least 2 additional hours each year; and the named CMS topics. Verify the current exact training terms before field use. | No clinical judgment for administration; qualified subject-matter review of clinical content | Training lead, clinical educator, and program lead. | |
| Maintain approved practitioner and partner arrangements | Public 2026 requirement | Keep required rosters and CMS approvals current; beginning with the July 2026 rules, do not furnish GUIDE services through an RCC arrangement until the RCC is an approved partner; apply the current memory-care-unit eligibility rule. | No clinical judgment | Program, contracting, credentialing, and compliance staff. | |
| Maintain the participant service area | Public 2026 requirement | Keep service-area ZIP codes current in the Participant Portal, align only eligible residents of that area, and document a temporary residence when continuing services for a temporary move. | No clinical judgment | Program operations and enrollment staff. | |
| Monitor continuing eligibility and unalignment | Public 2026 requirement | Review final alignment information, act when CMS removes a patient or an unalignment condition arises, submit required unalignment information within the applicable deadline, stop billing on the correct date, and provide the required written patient notice. | Clinical review on trigger only when the reason involves a clinical attestation | Data custodian, program operations, billing staff, and clinician when a diagnosis attestation is involved. | |
| Handle moves to an unapproved RCC or Memory Care Unit | Public 2026 requirement | Apply the 60-day unapproved-RCC or 15-day Memory Care transition, coordinate care transition, assist with planning, and submit the unalignment PAAF when required. For Memory Care Unit unalignment, also submit final GUIDE claims within 30 days after the effective unalignment date; do not extend that special deadline to RCC transitions without controlling guidance. | Clinical review on trigger | Care navigator, program operations, data custodian, billing staff, and clinicians for clinical transition needs. | |
| Transfer a patient between GUIDE participants | Public 2026 requirement | Preserve free choice; notify CMS and the other participant within the current deadlines; verify the patient's preference without influencing it; exchange transition information; document the handoff; and repeat the required voluntary-alignment work at the receiving participant. | Clinical review on trigger | Care navigators, enrollment staff, data custodians, and clinicians for clinical handoff content. | |
| Establish monthly DCMP claim readiness | Public 2026 requirement | Before a monthly claim, confirm final alignment, an actually furnished non-respite GUIDE service, required contacts, current BAR tier and G-code, aligned service dates, approved rendering practitioner or partner status, and no prohibited duplicate billing or additional patient cost sharing. | No clinical judgment for claim readiness; clinical owner remains responsible for the underlying service | Billing, program operations, roster owners, and service-delivery staff. | |
| Cooperate with CMS monitoring and evaluation | Public 2026 core; detailed retention and audit terms pending Participation Agreement check | Make participant, practitioner, and partner model records available as required; respond to CMS surveys, interviews, site visits, and evaluation activity; verify exact retention periods, audit procedures, and corrective-action terms from the current agreement. | No clinical judgment for administration; clinical review for clinical records or explanations | Compliance, program operations, records owners, partner managers, and clinical leadership. | |
| Carry out the Health Equity Plan and voluntary equity-data work | Public RFA baseline; current particulars pending Participation Agreement and GUIDE Connect check | Develop and implement the plan, monitor goals and disparities, report required progress, and collect/report HRSN and standardized sociodemographic data only from people willing to disclose it; refusal must not block care. | No clinical judgment for administration; clinical review for clinical interventions | Health-equity lead, quality, data staff, care team, and compliance. | |
| Honor beneficiary claims-data-sharing preferences | Public RFA baseline; current procedure pending Participation Agreement and GUIDE Connect check | Explain how beneficiary-identifiable claims data may be shared for coordination and quality work and how the patient may change or opt out of that preference under the current CMS process. | No clinical judgment | Enrollment, privacy, program operations, and the patient or representative. | |
| Complete required care-delivery reporting | Public RFA care-delivery requirement; current-year fields, questions, and due dates pending Participation Agreement and GUIDE Connect check | Submit current care-delivery reporting and retain support for the responses. Do not assume that the older RFA's annual schedule or example fields are the current form. | No clinical judgment for reporting; clinical review where a response contains clinical content | Program operations, quality, and data owners. | |
| Submit and monitor performance-measure data | Public 2026 requirement | Use the current PAAF, submit complete and timely PROMIS-10 and applicable ZBI-22 data, monitor CMS feedback, and correct remediable data problems. Do not turn a population measure into an unsupported individual treatment rule. | Mixed | Data custodian and quality lead; clinicians own clinical actions. | |
| Keep GUIDE reporting separate from QPP MIPS | Beyond the public GUIDE minimum; still may be required under QPP when a practitioner remains MIPS-eligible | Complete any separate MIPS reporting that still applies; GUIDE reporting does not satisfy MIPS reporting. | No clinical judgment for submission; clinicians and quality staff own measure content | Quality, billing, data staff, and affected practitioners. |
This program work is now decomposed into 138 literal tasks in 18_GUIDE_Program_Operations_Tasks.md: 79 are direct current-public 2026 requirements, 26 are public-RFA requirements awaiting current Participation Agreement confirmation, 29 are necessary delivery work, and 4 are beyond the public GUIDE minimum. Five rows contain clinical judgment, 43 use clinical review on a defined trigger, and 90 contain no clinical judgment. It remains separate because this work should not be hidden inside one of the eight care-service SOPs.
Services Proxi should consider beyond minimum compliance#
The public GUIDE floor is substantial, but it is not the ceiling for a high-value dementia-care service. The following additions are supported by authoritative guidance or evaluated dementia-care programs. They are candidate business services, not claims that CMS currently requires them.
| Candidate service | What Proxi would actually provide | Why customers would value it | Clinical boundary | Evidence anchor | Review |
|---|---|---|---|---|---|
| Longitudinal caregiver coaching | Turn one-time education into recurring, personalized practice: rehearse responses, revisit what worked, adapt routines, and reinforce skills as dementia changes. | Builds caregiver confidence and reduces the gap between receiving information and using it at home. | Trained navigator or educator can coach approved skills; new symptoms, safety questions, or treatment issues go to a clinician. | NICE dementia recommendations, §1.11.1; WHO iSupport | |
| Behavior and distress prevention | Help the dyad identify patterns, unmet needs, environmental contributors, and non-drug strategies; maintain a usable response plan for recurring distress. | Addresses one of the most burdensome day-to-day problems for families and may prevent avoidable crises. | A clinician evaluates possible medical causes and treatment; trained staff can collect patterns and coach an approved plan. | NICE dementia recommendations, §§1.7.1-1.7.10 | |
| Fall-prevention service | Repeatedly ask about falls and near-falls, support home-risk correction, medication and vision follow-up, strength and balance referrals, and completion tracking. | Protects independence and reduces a common reason for emergency care or loss of community residence. | A qualified clinician assesses fall risk and treatment; navigation, reminders, and environmental follow-through can be non-clinical. | CDC STEADI | |
| Wandering and missing-person preparedness | Create a personalized prevention and response plan, capture patterns and safe contacts, review identification and notification options, and rehearse what the caregiver will do. | Converts a frightening possibility into a practical plan before a crisis occurs. | Clinical or safeguarding judgment is required for individualized risk and restrictions; preparation and approved education can be non-clinical. | NIA wandering guidance | |
| Hearing and vision optimization | Go beyond recording a screen: close referrals, solve appointment and device-use barriers, and check whether corrected sensory problems improve communication and function. | Sensory problems can amplify confusion, isolation, and caregiver difficulty while remaining practically addressable. | Screening and clinical treatment stay within professional scope; navigation and device-routine support can be non-clinical. | NICE dementia recommendations, §§1.8.10-1.8.11 | |
| Personalized medication-use support | After clinician reconciliation, design a feasible home routine, resolve access or packaging barriers, teach the approved schedule, and monitor adherence problems and side effects for escalation. | Makes the clinician-approved regimen workable in the beneficiary's actual home context. | Medication decisions and side-effect interpretation remain clinical; routine support and observation can be delegated. | AHRQ MATCH medication reconciliation; NICE medicines adherence | |
| High-touch recovery after care transitions | Contact the dyad early after a transition, confirm understanding of the discharge plan, medications, appointments, equipment, home services, and warning signs, and continue until the handoff is actually functioning. | Families often experience transitions as fragmented and confusing; closed-loop recovery is immediately visible value. | Clinical interpretation of symptoms, orders, and medication changes stays with clinicians; verification and coordination can be non-clinical. | AHRQ RED follow-up tool; NICE dementia recommendations, §1.12.2 | |
| Early and recurring future planning | Revisit goals, legal and financial preparation, preferred decision makers, advance-care planning readiness, and likely future care needs before a crisis forces decisions. | Gives beneficiaries more voice and gives families time to prepare. | Medical orders and clinical counseling stay with authorized professionals; education, preference capture, and referrals can be non-clinical. | NICE dementia recommendations, §§1.1.12-1.1.14 | |
| Meaningful activity and social connection | Build an individualized activity and connection plan from the person's history, interests, strengths, culture, and current function; remove practical barriers to participation. | Supports identity, enjoyment, relationships, and daily structure rather than treating care as problem management alone. | Clinical or therapy input is needed when the activity carries individualized safety or rehabilitation implications; ordinary preference matching and navigation are non-clinical. | NICE dementia recommendations, §§1.4.1-1.4.3 | |
| Functional independence and reablement | Identify tasks the person wants to retain, arrange occupational-therapy or cognitive-rehabilitation support when appropriate, and help the dyad practice the approved strategies at home. | Preserves agency and community living rather than only documenting decline. | Evaluation and therapy plans belong to qualified clinicians or therapists; practice support and barrier resolution may be delegated. | NICE dementia recommendations, §1.4.4 | |
| Acute-change, pain, and delirium detection | Teach the dyad what changes warrant prompt contact, establish an easy route to report them, compare new observations with the person's baseline, and ensure timely clinical handoff. | Helps families obtain the right help earlier and reduces the chance that a serious change is dismissed as “just dementia.” | Assessment, diagnosis, urgency, and treatment are clinical. Proxi and trained staff can collect observations and expedite handoff. | NICE dementia recommendations, §§1.7 and 1.8 | |
| Nutrition, hydration, and swallowing support | Monitor practical eating and drinking problems, help implement clinician-approved strategies, resolve meal and supply barriers, and obtain clinical or speech-language evaluation when concerns appear. | Addresses daily health, comfort, and caregiver burden in a concrete way. | Swallowing assessment, aspiration risk, and treatment are clinical; routine observation and support can be delegated. | NICE dementia recommendations, §§1.10.6-1.10.8 |
Evidence that a non-clinical navigator model can create meaningful value when backed by specialists is not merely theoretical. The Care Ecosystem randomized trial used telephone and internet-based care-team navigators with nurse, social-work, and pharmacy backup and reported better quality of life along with reductions in emergency-department use, caregiver depression, and caregiver burden. That supports a deliberate split: navigators perform the longitudinal relationship and execution work; clinicians take the judgment that requires their license.
Calibration examples across the work#
These examples show how the three classifications work together. They are the calibration standard for classifying every task in the eight service tables.
| Work example | GUIDE standing | Customer-value position | Clinical lane | Why | Review |
|---|---|---|---|---|---|
| Obtain and document exclusive GUIDE service consent before the initial assessment | Public 2026 requirement | Compliance infrastructure | No clinical judgment | It is a current alignment prerequisite and a patient choice, not a medical decision. | |
| Perform the cognition-focused examination | Public RFA care-delivery requirement | Core customer value | Clinical judgment required | The examination and its interpretation cannot be delegated. | |
| Retrieve and organize records before the assessment | Necessary delivery work | Value through better execution | No clinical judgment | CMS requires a comprehensive result, while this exact preparation method is Proxi's operating choice. | |
| Administer a configured depression screen | Public RFA care-delivery requirement | Core customer value | Clinical review on trigger | Structured collection can be delegated; concerning answers and clinical interpretation cannot. | |
| Determine the response to suicidal thoughts or imminent harm | Necessary delivery work | Core customer value | Clinical judgment required | Severity, immediacy, disposition, and treatment require qualified human judgment. | |
| Clinically synthesize the comprehensive assessment | Public RFA care-delivery requirement | Core customer value | Clinical judgment required | Facts become a clinical and service picture through professional interpretation. | |
| Schedule and remind participants about the care-planning conversation | Necessary delivery work | Value through better execution | No clinical judgment | It enables participation but is logistical. | |
| Let the beneficiary lead goals and decide caregiver involvement | Public RFA care-delivery requirement | Core customer value | No clinical judgment | The beneficiary is exercising preference and authority, not clinical judgment. | |
| Decide the clinical interventions in the care plan | Necessary delivery work | Core customer value | Clinical judgment required | Medical recommendations must come from an appropriately licensed clinician. | |
| Keep 24/7 human access available | Public RFA care-delivery requirement | Core customer value | Clinical review on trigger | Human support is mandatory; routine calls can be handled without a clinician, while medical and safety concerns escalate. | |
| Maintain a coverage rota and verify the line works | Necessary delivery work | Compliance infrastructure | No clinical judgment | It is Proxi's means of reliably providing continuous access. | |
| Complete the tier-specific substantive navigator contact | Public RFA care-delivery requirement | Core customer value | Clinical review on trigger | A trained navigator owns the contact; medical or complex issues move to clinical staff. | |
| Notice a material change during routine contact and determine its medical urgency | Necessary delivery work | Core customer value | Clinical judgment required | The navigator can recognize and report the change; a clinician determines clinical significance and response. | |
| Verify that an outside PCP received the current care plan | Necessary delivery work | Value through better execution | No clinical judgment | Closed-loop verification makes the required access real. | |
| Decide that a new specialist evaluation is clinically indicated and how urgent it is | Beyond the public GUIDE minimum | Core customer value | Clinical judgment required | RFA §5.2 permits the referral route; if offered, clinical necessity and urgency cannot be delegated. | |
| Obtain the specialist note and track the agreed follow-up | Public RFA care-delivery requirement | Value through better execution | No clinical judgment | Once the referral occurs, the RFA requires return documentation and loop closure; interpreting the note is clinical. | |
| Match a stated social need to available community services | Public RFA care-delivery requirement | Core customer value | No clinical judgment | The navigator can provide preference-sensitive resource navigation without practicing medicine. | |
| Decide whether a proposed community service is safe given a clinical condition | Necessary delivery work | Core customer value | Clinical judgment required | Clinical suitability is different from resource matching. | |
| Assemble the best-possible medication list from conflicting sources | Necessary delivery work | Value through better execution | Clinical review on trigger | Staff and Proxi can collect and normalize; unresolved conflicts go to the prescribing clinician. | |
| Reconcile medications and decide whether to prescribe or deprescribe | Public RFA care-delivery requirement | Core customer value | Clinical judgment required | Medication reconciliation and treatment decisions require prescribing authority. | |
| Deliver approved caregiver skills training | Public RFA care-delivery requirement | Core customer value | Clinical review on trigger | Trained staff can teach approved content; individualized medical or safety questions escalate. | |
| Provide recurring personalized caregiver coaching after the required training | Beyond the public GUIDE minimum | Additional evidence-backed value | Clinical review on trigger | Longitudinal coaching adds value while preserving the clinical boundary. |
The resulting Proxi labor model#
The business split should be:
- Licensed clinicians: diagnosis, clinical examination, interpretation, risk and urgency, treatment, reconciliation, prescribing, clinical care-plan decisions, medical orders, and exception review.
- Trained human care navigators and other non-clinical staff: relationship ownership, preference capture, approved education, routine monitoring, resource navigation, coordination, practical problem solving, and closed-loop follow-through.
- Proxi: information collection, record assembly, normalization, reminders, drafting, approved education delivery, missing-information detection, routine tracking, and surfacing defined concerns to the responsible person.
The operating principle is: delegate the work around the judgment; never delegate the judgment itself.
Next business pass#
The classification and decomposition work is complete across 603 tasks. 20_Proxi_Service_Offer_and_Workforce_Model.md now contains the proposed business offer and staffing basis.
- Accept or correct the proposed six core enhanced commitments, four partner-enabled standards, and two later packages.
- Convert the accepted base and enhanced services into role-by-role operating sequences grouped by entry, recurring, event-driven, standing, and back-office work.
- Measure occurrence volume and active minutes by role before estimating headcount; task-row counts are not workload.
- Compare every public-source requirement determination with the executed Participation Agreement, Appendix D, and current GUIDE Connect instructions when those documents are supplied.