Roles and escalation

Status: v0.2

Authority lanes and cost levels#

Performer assignment and design blockers#

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.
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

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.

The current provisional staffing scenario uses 341 established-year nonclinical minutes for the Puerto Rico L2 lane, 74 minutes for the separate U.S. L3 pool, and 106 minutes for the separate U.S. L4 pool per aligned beneficiary-year. Approval or replacement remains open under O-039. Approximately 60–65 of the L3 minutes are expected RN work and 7–10 are portfolio-average LCSW or behavioral-clinician work; this does not mean both roles touch every beneficiary. No L3 or L4 minute is Puerto Rico navigator labor.

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. Actual re-send remains blocked until O-001 and every applicable release decision (O-014 for care-plan distribution, O-021 for Care Coordination, and O-030 for Medication communication, including multiple decisions when they overlap) are settled and an authorized-human release event covers the exact recipient, purpose, channel, and version.
• 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