Roles and escalation

Status: v0.2

Authority lanes and cost levels#

Performer assignment and design blockers#

Under D-031, Philippine L1 performs the manual transport of an approved coordination provider packet or clinician-approved medication recommendation to its authorized PCP/specialist when automated transmission is unavailable. The worker sends the unchanged approved payload and records delivery/failure; the coordination worker also pursues factual receipt. This does not confer clinical interpretation, provider-agreement determination, patient-order delivery or human release authority. All required clinical authorship, permission and class-specific release occur first. O-014 Care Plan sending, D-007 community-referral release and other destinations remain separate.

Under D-032, the accepted primary PR navigator first meets the family during initial assessment/planning, in genuinely useful existing planning/support work. State the named contact, working help route, next useful action and honest CMS status. No additional welcome call, clinical gate or automatic service/claim credit is created; actual time is counted once in its parent episode.

An outbound release check is not clinical merely because the packet contains medical information. D-033 removes an extra per-packet OK only for the two approved-rule routine provider classes; approved software authorizes their clean send, and D-031 Philippine support is only the manual courier when automation is unavailable. A genuinely required individual review uses its actual authorized person. D-007's ordinary community-referral check remains with the assigned navigator or designated navigator-lead backup. Other classes keep their own accepted authority; no generic clinician, navigator or privacy reviewer is added. The four-task breakdown separates these acts; an independently due/new/conflicting clinical act is not waived.

For the 24/7 roster, Leon's current staffing choice is Philippine nurses performing the nonclinical first-answer function within L1 (D-026). Nursing education can help with accurate vocabulary, source capture and approved stop-cue recognition; it does not turn this function into clinical triage or U.S. nursing practice. The public human-helpline requirement does not mandate a Puerto Rico or licensed-clinical shift around the clock. An approved caregiver-support care-team capacity, clinical response or emergency route is a separate act with its own entry and response rule. Philippine care-team membership/support scope remains O-001; additional after-hours clinical promises remain O-054. The $5.50/hour L1 figure is an inherited blended planning assumption, not a verified all-in Philippine-nurse wage.

For every licensed act, identify who receives that act, not just who speaks. A caregiver reporting the beneficiary's symptoms does not change the beneficiary's clinical location. A separate clinical assessment or treatment of the caregiver uses the caregiver's own current location and the professional's authority for that act. If both receive licensed care, check each separately; also verify applicable provider-location requirements. Nonclinical caregiving coaching does not become a licensed assessment merely because a nurse delivers it. SRC-HHS-TELEHEALTH-LICENSURE and SRC-HHS-TELEBEHAVIORAL-LICENSURE support this distinction, not permission for any particular jurisdiction.

No actor family, pool, department, queue, function label, or unresolved authority performs work. This rule applies to every human row, including Proxi specialists and GUIDE Participant retained or nondelegable acts.

• No human act: when the approved trigger is false or the clean path requires no person, show no human participant and create no human work item.
• Approved human act: the SOP names the human category, authority basis, exact act, inputs, output, return recipient, timing, and failure route. At runtime, one authorized individual or specifically approved Participant body is assigned and accepts before the work begins.
• Unresolved performer or authority: show the affected work only as SOP DESIGN BLOCKED — NOT OPERATIONAL outside the performer list. Identify the controlling decision and the independent work that may continue. Do not create a runtime assignment.
• Staffing or acceptance failure: an approved branch uses its preapproved backup and named escalation actor. If either is absent, the branch is design-blocked; staff do not choose an improvised performer or escalation owner at runtime.

For a GUIDE Participant act, the SOP must name the actual retained or nondelegable act and the approved Participant body, role, or authorized individual that performs it. GUIDE Participant accountable authority is a roster family, not a person. While the executed Participation Agreement or the retained-act assignment remains unresolved under O-PA-001, the affected branch cannot activate and no abstract Participant authority may appear as its performer.

There is no Proxi “specialist pool” in a beneficiary workflow. Privacy, disclosure, outreach, routing, staffing, duplication, attribution, billing, and other approved policies are enforced in software. A generic Quality, Privacy, Program, Operations, Data, or Compliance specialist is not a case performer. Missing facts return to the person who can actually obtain them; an operational failure returns to the responsible worker and same-lane lead; a genuine technical, financial, workforce, clinical-leadership, Medicaid, or legal problem routes to the real job that can resolve it.

Real-job routing when routine work fails#

1. Routine completion or correction. Software applies the approved rule. The original L1, L2, clinician, or outside performer completes or corrects the work. No additional reviewer is added merely because evidence is missing, a deadline was missed, or a duplicate was detected.
2. Same-lane supervision. When the owning SOP's repeat-failure, dispute, or reassignment trigger is met, the Philippine L1 team lead, Puerto Rico navigator lead, or applicable clinical supervisor performs the exact recovery act. “Quality” is the responsibility of that lead, not a separate person floating above the episode.
3. Concrete enabling problem. System configuration, access, permissions, telephony operation, or environment failure goes to the System Administrator. Incorrect implemented behavior or missing automation goes to Software Engineering. Claim and payment work goes to Billing/Revenue Cycle. Medicaid authority or coverage questions go to the Medicaid Program Specialist. Roster, leave, credential-file, and workforce-capacity gaps go to HR/Workforce Administration.
4. Protected professional escalation. Nursing-practice quality goes to the Head of Nursing/Clinical Operations. Physician or medical-quality review goes to the Chief Medical Officer. A complete fact pattern that exposes a genuine uncovered legal question goes to Legal Counsel. These authorities do not bless routine work. Business commitment: the designated Administrative Manager approves a new partner contract or change to Proxi's committed services/coverage area under D-027, using prepared terms, cost, capacity and restrictions. The manager is not a routine case approver and does not supply legal advice, clinical judgment, CMS approval or an unproved Participant-retained signature.
5. Policy gap. Software holds only the affected act. The accountable policy and organizational owners approve a reusable rule outside the beneficiary episode. Once approved, software enforces it. A policy-gap item is not a runtime assignment to an unnamed human.

Every assigned person performs one bounded act, records the output, and returns it to the service worker responsible for the affected action. Portfolio QA sampling, workforce repair, software incidents, and policy maintenance remain outside the beneficiary service episode and never become service credit.

Canonical actor names#

Every reviewer-facing workflow must identify a person by this roster, not by an episode function invented for one diagram. The canonical human and outside-party families are:

1. Philippine 24/7 and coordination support (L1)
2. Puerto Rico GUIDE navigator (L2)
3. U.S. clinical support RN (L3-RN)
4. U.S. LCSW or behavioral clinician (L3-Behavioral)
5. U.S. prescribing or Part B E/M clinician (L4)
6. System Administrator
7. Software Engineering and debugging team
8. Billing and Revenue Cycle Specialist
9. Medicaid Program Specialist
10. HR and Workforce Administration
11. Head of Nursing and Clinical Operations
12. Chief Medical Officer
13. Healthcare Legal Counsel
14. GUIDE Participant accountable authority, which is never itself a performer; an operational branch must name the actual retained or nondelegable act and the approved Participant body, role, or authorized individual assigned to perform it
15. Beneficiary
16. Caregiver or decision-specific authorized representative, with caregiver participation kept separate from representative authority for each decision
17. External party (L5), with the actual subtype named: PCP, specialist, pharmacy, hospital/facility, emergency service, payer, community organization, Medicaid/AAA/Tribal Aging Program, or other endpoint
18. Administrative Manager, the designated Proxi business approver for new partner contracts and changes to committed services or coverage areas under D-027; this is one real employment category, not a separate role for each contract or service

The Philippine L1 team lead or QA nurse is an exact supervisory capacity inside the L1 employment category. The Puerto Rico navigator lead is an exact supervisory capacity inside the L2 employment category. They are not separate universal “quality” actors. Care Plan owner, Assessment team, sending owner, receiving owner, service owner, support owner, coordination, trainer, and similar phrases describe an assignment or function. They are not additional job categories. A workflow may show one of those functions only beside the canonical actor who performs it. If the authorized performer is unresolved, show the affected work only as an SOP DESIGN BLOCKED — NOT OPERATIONAL item outside the performer list, linked to the controlling decision. The design blocker prevents activation of the affected branch; it does not prevent explicitly independent branches from continuing or the draft from being reviewed.

Deterministic software, bounded AI, the Daily Companion, external systems, records, packets, ledgers, calendars, queues, and work obligations are nonhuman. They appear in separate software or work-product lanes and never in an actor list. A person label that does not resolve to this roster is an unmapped phantom actor and must fail publication. A design blocker may describe a missing assignment, but it must never masquerade as a person or runtime work owner.

One roster family does not merge caregiver and representative status. A caregiver may participate without authority to decide, and a representative's authority is decision-specific. Workflows retain caregiver participation separately from the representative's evidence, scope, effective dates, expiry, and conflicts.

Rates are planning assumptions and must be maintained separately from workflow rules. Current reach and minute assumptions are in 22_GUIDE_Human_Workload_and_Staffing_Estimates.md.

Under D-028, the in-person residence visitor is an outsourced social worker or home-safety specialist acting as an approved GUIDE care-team/Partner worker. The role is a typed contracted capacity within External party, not a new universal specialist pool. That worker performs the structured onsite observation/context act; the separately assigned Proxi U.S. clinician participates through telehealth for the actual licensed assessment. Paid contracted GUIDE work is Proxi cost under D-012, not an excluded outside endpoint. Clinical, partner, location, title/qualification and modality requirements must be met; no label or video connection proves them.

The current illustrative established-year scenario in Human Workload produces 247.0 active PR L2 known-component minutes plus unresolved RCC caregiver/multiplicity additions, 47.8 U.S. RN minutes, 7.6 U.S. behavioral-clinician minutes and 98.1 U.S. medical-clinician minutes per beneficiary-year. These are episode-derived planning inputs, not observed utilization or CMS time requirements. The selected annual nursing/medical split is not a mandatory RN gateway. PR payroll retains 160 scheduled paid hours/month and 70% productive load under D-029; $22 pays every scheduled hour, not just active work. Approval/replacement of the quantitative inputs remains O-039, and unpriced availability/fees remain explicit.

For Medication Management, the L4 row is a provisional operating group, not proof that every §7.1-7.3 function belongs only to the listed titles. O-028 must establish the actual prescribing-authority, CNS/APN, pharmacist, collaborative-practice, RN, pharmacy-technician, jurisdiction, organization, and scope matrix before activation. If the dementia-proficient clinician is not a physician, the public RFA also requires a part-time physician medical director.

Philippine Coordination Support#

Permitted#

• Verify PCP, specialist, pharmacy, agency, fax, Direct address, and office information.
• Confirm referral or care-plan receipt.
• Request and chase records already authorized for release.
• Verify the endpoint and prepare an unchanged approved packet for re-send. For an ordinary nonclinical community referral, the assigned Puerto Rico GUIDE navigator—or the designated Puerto Rico navigator lead acting as the preapproved backup—performs the new exact V1 release event required by D-007. Other release classes remain governed by O-001 and their applicable class decision (O-014 for care-plan distribution, O-021 for Care Coordination, and O-030 for Medication communication, including multiple decisions when they overlap).
• Confirm appointment date, service availability, waitlist status, or document completion.
• Schedule within beneficiary-approved constraints.
• Arrange an approved warm transfer.
• Capture verbatim external responses and choose from approved administrative outcome codes.
• Ask a caregiver to upload a previously requested document or bottle photograph.

Prohibited#

• Acting as the required GUIDE care navigator.
• Conducting medication reconciliation or clinical triage.
• Selecting providers or services for the beneficiary.
• Resolving caregiver disagreement or consent/authority questions.
• Explaining clinical rationale or giving medical advice.
• Relaying a new clinical order to the patient/caregiver.
• Determining urgency, completeness, clinical equivalence, billability, or closure.
• Free-form interpretation of an outside provider's clinical statement.
• Treating the Philippine RN credential as authority to triage, assess, reconcile medication, recommend treatment, prescribe, or issue an order for a U.S.-located beneficiary.

Stop conditions#

The VA stops the administrative workflow and invokes the deterministic escalation path when:

• Symptoms, medication instructions, or safety concerns arise.
• Clinical advice or judgment is requested.
• A provider disputes a medication or gives a new order.
• Legal representative authority is challenged.
• The caller is distressed, confused, threatening, or reports immediate danger.
• The response does not map safely to an approved administrative outcome code.

Human-task routing by unresolved authority#

The navigator is not the default validator for software-produced practical fit and is not the starting point merely because a choice is preference-sensitive. Software/AI should first collect the person's stated constraints and prior choices, retrieve and compare current facts, build the viable options and tradeoffs, and ask the person directly when an approved digital or AI route is sufficient. The navigator receives that prepared choice packet and enters only when the person requests human help, a required GUIDE human contact is being furnished, ambiguity/disagreement/distress remains, or relationship work can materially change the result. The navigator does not gather the packet again and does not bless a clear choice merely to create human minutes.

The same preparation rule applies to clinical work. Software/AI and L1 assemble the source material, literal contradictions, missing facts, prior instructions, and the exact clinical question. The packet routes directly to the beneficiary-location-authorized clinician for the protected act; L2 is included only when separate relationship or preference context is genuinely needed. The clinician reviews the packet, performs any examination or clinically necessary history, and exercises judgment. The clinician is not the default chart hunter, form filler, scheduler, or record chaser. Clinical suitability and all other protected judgment remain with the qualified clinician, not with AI, the navigator, or L1.

Provisional urgency classes#

These are operating targets, not CMS mandates. They remain PROVISIONAL pending clinical and contractual approval.

VA capacity arithmetic#

At $5.50/hour, direct cost is $0.0917 per minute. At 75% productive utilization, one FTE supplies approximately 7,200 productive minutes per month.

Staffing cost must be calculated from observed event incidence:

PMPM role cost = monthly event incidence × mean minutes/event × role cost/minute