Status: Settled commercial scope with provisional field-workload assumptions
Date: 2026-07-12
Scope: The eight GUIDE services in scope, GUIDE program operations, and candidate enhanced dementia-care services. Respite delivery remains excluded.
Decision in plain language#
Proxi should not sell 603 tasks or 12 disconnected enhancements. It should sell one coherent GUIDE operating service with three promises:
- Run the GUIDE work reliably. Support the participant across intake, alignment, assessment, care planning, human access, monitoring, coordination, referral, medication work, caregiver support, reporting, and billing readiness.
- Make required care feel materially better. Use preparation, personalization, reminders, and closed-loop follow-through so the beneficiary and caregiver experience continuity rather than a compliance checklist.
- Add a bounded dementia-care layer. Commit first to the enhanced services Proxi can materially deliver with navigators and defined clinical backup; use qualified partners where the decisive service is therapy, specialty care, legal work, or another external professional function.
The commercial boundary is settled: Proxi fulfills all eight GUIDE service domains in scope and respite alone is excluded. Proxi may use employees, contracted licensed professionals, and approved partners, but it does not leave assessment, navigation, 24/7 access, caregiver services, program operations, or required clinical capacity as an optional customer-supplied package.
The participant remains the GUIDE Participant. A human care navigator remains the primary contact. The Puerto Rico navigator operation is strictly nonclinical; Proxi's separate U.S. clinical workforce retains every clinical and medical act. Beneficiaries and caregivers retain their choices. External providers remain responsible for the services only they can furnish.
The current public-source operating inventory contains 497 tasks: 481 in the working public-source floor and 16 optional or beyond-minimum paths already present in the care-service and program-operation files. The 106 enhanced tasks are additional candidate value, not hidden requirements. Final compliance still requires the executed PY 2026 Participation Agreement, contractual Appendix D, current GUIDE Connect instructions, and live participant manuals.
What the operating words mean#
These are plain business meanings, not workflow states, mandatory labels, or software fields. Each task card still defines its own evidence.
- Available: Proxi maintains a staffed, working capability, such as the 24/7 line, education library, navigator roster, or clinical roster. Availability costs money but does not by itself furnish a person-level service or support a claim.
- Applicable: The person's current need, request, cadence, assessment, event, or accepted plan makes the service relevant now. A caregiver service is not applicable when there is no caregiver; that is not failure or refusal.
- Offered: A specific service was explained to a specific person with its purpose, expected result, likely burden, performer, and material limits. An offer is not delivery.
- Accepted, declined, or deferred: The person chose yes, no, or not now. Acceptance permits the next work but does not prove it occurred. A decline is preserved without repeated pressure. A deferral identifies when or why the offer may return.
- Arranged: The logistics exist—an appointment, introduction, order, referral, or delivery plan. Arrangement does not prove that an outside service occurred.
- Furnished: The authorized actor performed the substantive person-specific service or care action. Only an actually furnished non-respite service can anchor a claimed month. Availability, reminders, attempts, passive monitoring, and administrative pursuit alone are not furnished services.
- Completed: The particular service episode reached the endpoint defined by its SOP, including a truthful non-success result when the intended endpoint could not be achieved. Completion may occur after furnishing and does not necessarily close the person's broader need.
- Helpful: The beneficiary or caregiver reports that the service helped, partly helped, did not help, or was not tried. This guides quality and next actions; it is not billing evidence.
Five different questions about whether work is done#
| Question | Who answers it | Evidence required | Review |
|---|---|---|---|
| Was a service furnished? | The performing service owner | The actual interaction or care action and its substantive content | |
| Was that service work completed? | The service/episode owner | The endpoint evidence required by the applicable SOP | |
| Is the broader loop or case closed? | The owner of the broader need | Every applicable obligation completed or left with a truthful result, current treatment, next owner, and follow-up | |
| Is the beneficiary-month claim-ready? | The billing owner | Alignment, tier, cadence, a furnished service, actor/date, and all required evidence under PO-122 | |
| Did the service help? | The beneficiary or caregiver | That person's own report |
None of these answers substitutes for another. A service can be furnished while a referral remains open. A real service in a month with an overdue touchpoint is care without a claim-ready month. A closed administrative case is not a furnished service. A claim-ready month does not prove the person found the service helpful.
The beneficiary and caregiver journey#
This is the minimum operating narrative. Detailed mechanics remain in 18_GUIDE_Program_Operations_Tasks.md and the service SOPs.
| Stage | What the person experiences | Primary handoff owner | What must be true before moving on | Review |
|---|---|---|---|---|
| First contact | One plain conversation about why GUIDE may fit, not a battery of disconnected forms; no promise that CMS will align the person | Intake/enrollment staff | No known disqualifier and the person wants the GUIDE explanation | |
| Explanation and choice | Voluntary participation, exclusivity, choices, likely process, and right to stop explained without pressure | Enrollment staff introduces the primary navigator after consent | Documented choice to proceed, or a respectful refusal that stops the path | |
| Assessment | The person is asked each fact once when possible; existing records answer what they can; nonclinical and clinical work are visibly separated | Navigator owns participation; the separate U.S. clinical team owns clinical content | A complete assessment or a truthful identified gap/disposition | |
| CMS waiting and alignment | Honest status while CMS processes the result; no implication of alignment before the authoritative result | Program operations owns CMS mechanics; navigator owns person-facing status | Final aligned result or truthful non-alignment explanation | |
| Welcome and activation | One named navigator, preferred contact method and participants, cadence in plain language, the 24/7 route, and the next planning conversation | Primary navigator | Welcome completed and the Care Plan conversation scheduled | |
| Care Plan | Goals and choices in the person's words; every accepted action has an owner; clinical content comes from the correct professional | Navigator facilitates; accountable Care Plan owner completes; clinicians own only their scoped decisions | Current plan reviewed, completed, and distributed as permitted | |
| Ordinary months | One continuing navigator who remembers prior work, contacts for a person-specific reason, bundles useful work, and stops when the result is reached | Primary navigator | Continuous while aligned; each contact or service has its own truthful result | |
| When something happens | Immediate human first answer; emergency, clinical, practical, caregiver, medication, transition, and referral work go to the right people without forcing repeated retelling | The owner of the actual episode | The person receives the result, a truthful pending plan, or an authorized non-success outcome; open actions return to the navigator | |
| Annual renewal | A fresh review of what changed, what still fits, and what should continue, consolidated with other due work when appropriate | Assessment team and navigator | Annual assessment/plan work completed and submitted as required | |
| Transfer, stopping, or exit | A neutral ending, continuity information, and a real person-facing goodbye; unfinished care is not hidden by administrative closure | Program operations owns CMS mechanics; navigator owns the person-facing handoff | Required notices, permitted information transfer, and every remaining obligation given a truthful next owner |
Monthly service-load rule#
Proxi schedules to the beneficiary's tier contact cadence, not to a quota of eight service domains. The due substantive navigator contact is the ordinary monthly anchor for monthly-contact tiers. That one interaction opens with the person's change, concern, or chosen priority and combines only the care-plan, medication-use/access, coordination, caregiver, or no-caregiver work that is relevant and actually furnished, spending most of its time on the one or two matters useful that day.
The business order is person need or required cadence → specific service → useful beneficiary/caregiver result → human time → billing classification. Before a planned contact, Proxi must be able to name why a conversation is appropriate now, what service the navigator will furnish, what should be better or clearer for the person afterward, and why the person's participation is needed. “Monthly check-in,” “engagement,” elapsed time, or an empty billing month is not a service proposition. A stable required contact can still have value when it gives the person a real choice of agenda and completes a specific ongoing-support result, including attributable confirmation that one current goal/action still fits and no added help is wanted.
The proposed 8 / 15 / 25-minute direct-interaction bands follow the work: a stable brief continuity or focused service; an ordinary one-need problem-solving service; or extended nonclinical, multi-action, or accessibility-supported work. They are not packages to fill. An unasked topic remains unasked, not “no change.” Clinical or safety complexity routes to the separate U.S. authorized workforce and is never absorbed into Puerto Rico navigator minutes.
Medication reconciliation, whole-plan reviewed-no-change work, clinical review, caregiver training, referral follow-through, and other services occur when an assessment, request, event, open obligation, accepted service, or real patient-specific need makes them due. They are not added merely to preserve a monthly claim. In low-dyad and RCC off-contact months, Proxi uses actual non-contact work when it naturally exists; otherwise the month is left unbilled. A qualifying inbound interaction replaces a redundant planned contact. The detailed menu, tier rotation, minute assumptions, and burden protections are in 23_GUIDE_Low_Burden_Monthly_Service_Plan.md.
Who completes the task#
Every operating sequence should name one completion owner. The owner is the actor whose final action makes the task true, not everyone who assists along the way.
| Completion owner | What completion means | Typical examples | Review |
|---|---|---|---|
| Proxi routine work | Proxi retrieves, organizes, compares, calculates, drafts, prepares reminders, tracks, or surfaces an exception without making a protected decision or independently releasing an external action. | Assemble an assessment packet; calculate a due window; retrieve a CMS result; track a response; flag an obvious possible duplicate. | |
| Beneficiary, caregiver, or authorized representative | A person supplies lived facts, chooses, consents, refuses, states a preference, teaches back, or participates. | Choose caregiver involvement; state a goal; accept or decline a service; give or refuse consent. | |
| Proxi-supplied trained non-clinical staff | A Puerto Rico dementia care navigator, Philippines first-answer/admin worker, coordinator, educator, enrollment worker, data custodian, compliance worker, or billing worker communicates, verifies, approves, releases, submits, teaches, or coordinates within role. | Conduct a qualifying navigator contact; facilitate a choice; verify a destination; submit a CMS file; release an approved communication. | |
| Proxi-supplied or Proxi-contracted U.S. clinical professional | A professional in the separate U.S. clinical workforce, outside the Puerto Rico navigator operation, acts within beneficiary-location authority and scope to perform examination, interpretation, individualized risk or urgency judgment, treatment, reconciliation, prescribing, or another clinical act. | Interpret cognition and stage; reconcile medicines; determine urgency; select treatment; sign a medical order. | |
| External party | CMS, an outside clinician, pharmacy, hospital, vendor, community organization, facility, emergency service, or other outside actor must furnish the endpoint. | Return requested records; fill a prescription; provide therapy; confirm an appointment; furnish emergency response; issue a CMS result. |
If one task contains two independently necessary completion acts owned by different actors, the operating SOP should split it into two steps. Preparation does not become authority, and pursuit does not become external performance. Software can complete routine scheduling, reminders, calculation, retrieval, matching, and tracking. Current V1 outbound PHI packets still use an authorized release click; future automatic release remains an open policy decision.
How much Proxi can do#
The completion owner, the presence of a beneficiary or external person, and Proxi's paid labor are separate questions. The deeper task-by-task analysis in 21_Proxi_Side_Labor_and_Automation.md produces this result:
| Proxi automation band | Public operating inventory | Enhanced inventory | Total | Meaning | Review |
|---|---|---|---|---|---|
| Definitely software | 92 | 2 | 94 | No paid Proxi human belongs on the ordinary path once required data, permission, and connection exist. | |
| Deterministic + AI | 237 | 42 | 279 | Software and bounded AI do the substantive Proxi work; a participant customer may make a narrow attestation or V1 release click, and people handle exceptions. | |
| Gray area | 72 | 31 | 103 | AI-first delivery is plausible, with a named human available for failed comprehension, requested contact, unsettled authority, sensitive coordination, or another defined fallback. | |
| Unquestionably human | 96 | 31 | 127 | The task contains explicit GUIDE human service, clinical judgment, physical or hands-on work, facilitation, negotiation, or genuine exception resolution. Under the settled full-service offer, the applicable in-scope human work is a Proxi cost even when furnished through a contracted professional or partner. | |
| Total | 497 | 106 | 603 | Task types, not case volume, minutes, or staffing ratios. |
Therefore, 373 of 603 task types have no routine Proxi-paid human on the clean path. Beneficiary and caregiver actions, participant-customer clicks or professional decisions, and external-provider delivery are tracked separately rather than charged to Proxi labor.
The base Proxi service by work family#
| Work family | What Proxi routinely contributes | Indispensable human work | Where the clinician enters | Review |
|---|---|---|---|---|
| Program operations | Deliver approved model explanations through text, video, voice, and in-scope AI; capture beneficiary choices; complete clean factual checks; populate and submit permitted data; generate notices and claims; maintain rosters and evidence; track PAAF, BAR, reporting, billing, transfer, and unalignment work. | The beneficiary or representative chooses. Participant staff make narrow factual or clinical attestations, approve only transactions their policy reserves for review, negotiate contracts, and resolve genuine exceptions. Clean scheduling, documentation, notice, PAAF, and claim work should not require Proxi staff. | Diagnosis and staging facts, dementia attestation, and disputed clinical information. | |
| Comprehensive assessment | Prepare scheduling options and reminders; gather records; present structured questions directly; preserve source and speaker; prepare summaries and exact professional questions; identify missing, stale, or conflicting information. | Beneficiary and caregiver provide information directly where possible; navigator coordinates only required/requested human participation and relationship exceptions; appropriate professionals receive prepared packets and perform the required assessment domains. | Examination, clinically necessary history, interpretation, staging, clinical risk, medication reconciliation, diagnostic conclusions, medical orders, and clinical synthesis. | |
| Person-centered care plan | Bring assessment findings together; organize goals, needs, options, owners, and open work; present prepared options for direct choice; draft the plan from accepted decisions; prepare authorized distribution and track follow-through. | Beneficiary leads goals and choices directly where possible; navigator enters for a required/requested human planning service, ambiguity, disagreement, distress, accessibility, warm introductions, or relationship work; authorized people participate as chosen. | Clinical options, treatment decisions, medication decisions, medical orders, and other clinician-owned content, each from a prepared exact question. | |
| 24/7 access | Operate the self-staffed Philippines human first-answer route; present authorized context; capture the report; invoke approved emergency, Puerto Rico nonclinical care-team, or separate U.S. beneficiary-location-authorized clinical escalation; document and track the handoff. | A Philippines human responder answers every hour. The Puerto Rico navigator supplies care-team-only substantive caregiver support and follow-up. The Philippines responder does not perform clinical triage or formal navigator contact. | Symptoms, medication questions, danger, abuse, self-harm, wandering, uncertain urgency, or another clinical concern go to the separate U.S. authorized clinical route. | |
| Ongoing monitoring and support | Calculate required cadence from current facts; prepare scheduling options and reminders; prepare the navigator; structure follow-up; carry forward promises and open work. | The human care navigator conducts the qualifying contact, maintains the relationship, listens, educates from approved material, and solves practical problems. | New or worsening symptoms, safety concerns, clinical questions, contradictions, unreliable information, or planned clinical reassessment. | |
| Care coordination and transitions | Obtain and organize records; prepare communications, exact clinical questions, and scheduling options; prepare approved requests for release; track authorized requests and practical dependencies until the handoff works. | Beneficiary/caregiver confirms prepared choices; Philippines staff owns administrative pursuit; navigator enters only for required/requested human coordination, ambiguity, disagreement, distress, requested introductions, warm handoffs, or relationship-dependent barriers. | Referral necessity and urgency, medication reconciliation, interpretation of outside information, conflicting recommendations, and treatment decisions from a prepared packet. | |
| Community referrals and supports | Maintain the resource inventory; use disclosed rules to filter and rank against stated constraints; explain matching factors and uncertainty; prepare outreach when the purpose, recipient, channel, and permitted information are established; schedule and track referrals, benefits, transportation, and external responses. Current V1 outbound PHI packets are prepared for one-click human release. | Beneficiary or caregiver defines the result and may choose directly. A Proxi VEA handles manual calls, dynamic facts, and failed electronic routes. The GUIDE navigator enters only for a required/requested human service, ambiguity, disagreement, distress, requested warm introduction, accessibility failure, or other relationship work—not routine searching, fit ranking, scheduling, status chasing, or a clear choice. | Clinical suitability, urgent or safety concerns, and questions about whether a service is medically adequate, each presented as a prepared exact question. | |
| Medication management | Gather all sources; keep source and date visible; conduct structured direct reported-use intake; organize discrepancies; prepare the exact reconciliation question; prepare approved access, supply, packaging, scheduling, and follow-up work for human or external action. | Beneficiary and caregiver report actual use directly; navigator enters only for a required/requested human interview or unresolved practical relationship barrier and reinforces the approved plan; pharmacy and outside providers furnish their parts. | Reconciliation, appropriateness, interactions, side-effect interpretation, prescribing, deprescribing, and lawful orders after packet preparation. | |
| Caregiver education and support | Schedule automatically; deliver the approved ten-topic course through short text, video, audio, translation, accessibility formats, and bounded text/voice AI; answer in-scope questions; collect the caregiver's intended use; prepare one focused application touchpoint; and track participation and follow-up. | The Alzheimer’s Association® essentiALZ®-certified Puerto Rico navigator owns one nonclinical plan-back/show-me touchpoint for the accepted skills-training event and provides the required direct diagnosis-information, facilitation, relationship support, and substantive caregiver-support calls. A person is not needed merely to schedule or deliver standard content, and the skills topics are not ten human lectures. | Medical or safety questions, physical techniques, severe distress, caregiver mental-health risk, individualized treatment issues, and other licensed acts route to the applicable Proxi clinical professional. |
Full-service fulfillment boundary#
No GUIDE service domain below is left for the Participant to staff as a separate customer-supplied package. “Participant-retained” means a legally or contractually nondelegable accountability, signature, attestation, approval, or CMS relationship—not that Proxi omits the service labor.
| GUIDE service domain | Proxi nonclinical fulfillment | Proxi clinical fulfillment | Participant-retained act | Outside endpoint that is not Proxi labor | Review |
|---|---|---|---|---|---|
| Comprehensive assessment and home visit | Software prepares and conducts permitted structured intake; beneficiary/caregiver confirms direct facts; Puerto Rico navigator handles only required/requested human nonclinical domains and relationship exceptions; Proxi coordinates participants and arranges the local home visit | Authorized clinical-support pool receives prepared clinical/psychosocial packets and supplies scoped judgment; E/M clinician examines, interprets, stages, synthesizes, and attests within authority | Accountability for compliant assessment completion, roster, and any nondelegable attestation | Outside records and, where contracted, the local in-person professional | |
| Person-centered care plan | Software prepares goals/options and the draft; beneficiary/representative may make clear authenticated choices directly; Puerto Rico navigator handles only required/requested human facilitation and relationship exceptions; Proxi maintains, distributes, and tracks the plan | Proxi clinician receives exact prepared questions and owns clinical conclusions, treatment content, medication decisions, and medical orders | Required accountable approval or signature that the agreement reserves to the Participant | PCP/specialist concurrence and outside treatment | |
| 24/7 access | Philippines team supplies continuous first answer; Puerto Rico navigator supplies care-team-only substantive caregiver support and follow-up | Proxi licensed pool performs triage and clinical response within beneficiary-location authority | Oversight of the approved coverage and Partner Organization arrangement | 911, 988, APS, hospital, or another emergency authority | |
| Ongoing monitoring and support | Puerto Rico navigator conducts qualifying contacts, relationship work, approved education, and practical problem solving | Proxi clinical pools review triggered symptoms, safety, behavioral, medication, or other clinical concerns | Accountability for meeting tier cadence and documenting delivery | Outside treating clinicians when their action is required | |
| Care coordination and transitional care management | Software and Philippines admin prepare packets, pursue records, communicate, schedule, and resolve administrative barriers; beneficiary/caregiver confirms choices; Puerto Rico navigator handles only required/requested human coordination, warm introductions, distress, disagreement, and relationship-dependent barriers | Proxi clinical pools receive prepared exact questions and determine clinical urgency/necessity, review returned findings, reconcile medication, and resolve treatment questions | Accountability for the required coordination service and approved disclosures | PCP, specialist, hospital, facility, pharmacy, and other treating entities furnish their own responses and treatment | |
| Referral and coordination of services and supports | Software filters and ranks with disclosed rules; Philippines admin verifies dynamic facts; beneficiary/caregiver may choose directly; Puerto Rico navigator handles only required/requested human choice support, warm introduction, distress, disagreement, accessibility failure, and relationship-sensitive coordination | Proxi clinician receives a prepared exact question and determines clinical suitability only when the referral requires it | Accountability for compliant delivery and approved partner arrangements | Community organizations, transportation, HCBS, AAA, and other service providers furnish the service | |
| Medication management and reconciliation | Software and Philippines admin gather sources and direct reported-use facts; Puerto Rico navigator addresses only required/requested human intake and unresolved access, supply, packaging, teach-back, or practical relationship barriers | Proxi prescribing-authority clinician receives the prepared packet and reconciles, assesses appropriateness and interactions, prescribes/deprescribes, and resolves clinical discrepancies | Accountability for maintaining the required service and qualified roster | Pharmacy and outside prescribers dispense, concur, or treat within their own authority | |
| Caregiver education and support | Software/AI delivers the main approved course; the Puerto Rico navigator supplies one focused nonclinical application/correction touchpoint and the separately required direct human services, facilitation, and support | Proxi RN/LCSW/behavioral or higher clinician enters for severe distress, mental-health risk, medical/safety questions, physical techniques, or individualized clinical issues | Accountability for offering, permitted-provider delivery, and documenting the required caregiver services | External group, therapy, or community provider furnishes a contracted endpoint when used |
The activation caveats in O-001 do not reopen this commercial boundary. They determine how Proxi must contract, roster, license, protect PHI, and document the already-settled service model before going live.
Two workforce boundaries are non-negotiable:
- The required GUIDE care navigator is not interchangeable with administrative coordination support. Administrative staff may prepare and pursue work, but they do not satisfy required navigator contact or replace the relationship.
- A general clinical reviewer is not automatically the correct prescriber, therapist, pharmacist, behavioral-health professional, or dementia-proficient clinician. The professional who enters must have the scope required by the actual decision.
Philippines and Puerto Rico staff may collect what a person reports, describe observable facts, reinforce clinician-approved instructions already in the record, deliver approved education, and arrange logistics. They may not tell anyone to start, stop, hold, skip, increase, or decrease a medicine; decide whether a symptom is urgent or can wait; choose among clinical options; create or change a behavior, safety, or medical plan beyond approved education; interpret a test result, discharge instruction, or medication change clinically; or reassure anyone that a new symptom or behavior is “normal for dementia.” When one of those acts is requested or appears necessary, the staff member states the limit plainly, records the person's words, and transfers to the separate U.S. clinical or emergency route. A nursing or other professional credential held outside the beneficiary's jurisdiction does not change this boundary.
The detailed separation of definitely-software, deterministic-plus-AI, gray, and unquestionably-human work is in 21_Proxi_Side_Labor_and_Automation.md. Beneficiary, caregiver, participant-customer, and external-party actions are separated there from Proxi-paid labor.
Recommended enhanced service offer#
The 12 candidate services should be packaged as three customer promises rather than 12 separate products.
Before an optional enhancement becomes a promise#
Proxi's full non-respite GUIDE obligation remains active regardless of the optional enhanced package. An enhanced item is marketed as an additional Proxi promise only after all six questions below have concrete answers:
- What Proxi itself furnishes: named acts performed by Proxi staff or a Proxi-contracted professional at Proxi's cost.
- What Proxi only coordinates: the decisive act belongs to an outside professional or organization, so Proxi promises access, preparation, barrier resolution, and follow-through—not that it performed the outside service.
- Who owns the protected act: the exact clinician, therapist, pharmacist, attorney, emergency authority, or other qualified professional, including required scope and beneficiary-location authority.
- Who pays: whether the work is funded within Proxi's GUIDE price, billed by an outside Medicare provider, covered through another benefit, supplied by a free/community program, or paid privately. Marketing must not imply Proxi pays for an outside act when it does not.
- What dependable capacity exists: occurrence assumptions and low/ordinary/high minutes for every Proxi role, funded clinical coverage for clinical triggers, and a working partner/referral route in each service area where the decisive act is external.
- How the service ends: goal met and follow-up completed; declined or discontinued; transferred to a named treating professional; or truthfully unresolved with the barrier and next owner visible.
Core enhancements do not become active commitments until O-052 records their expected incidence, role minutes, funded owner, and service-area capacity. Partner-enabled enhancements are described as referral and closed-loop coordination wherever Proxi lacks a dependable contracted professional endpoint. Required GUIDE transition support, caregiver education, monitoring, medication management, referral work, and 24/7 access remain baseline obligations; enhanced packaging may deepen them but never conditions or resells the required floor.
Promise 1: Caregiver confidence and behavior support#
- Longitudinal caregiver coaching — core commitment. Proxi structures the concern, matches it to approved lesson candidates for the human coach, supports rehearsal, records one home action, and brings the result back to the next conversation. A dementia-trained navigator or educator selects and provides the coaching; clinical or behavioral-health review enters on defined concerns.
- Behavior and distress prevention — core commitment when a concern exists. Proxi helps describe behavior observably, identify patterns and context, maintain the authorized response plan, and follow outcomes. Qualified clinicians assess medical causes, urgency, and treatment. The service must never relabel pain, delirium, infection, medication effects, abuse, or another acute problem as ordinary behavior.
Promise 2: Safe home execution and recovery after change#
- High-touch recovery after care transitions — core commitment after every applicable transition. Proxi supports pursuit and organization of discharge information, prepares the early recovery contact, tracks medicines, appointments, equipment, and home services, and keeps open work visible until the human team confirms that the handoff works. The early recovery conversation is a nonclinical navigator service. Clinical status review, symptom interpretation, disposition, and medication reconciliation are separate funded U.S. clinical work and are never Puerto Rico navigator work. Final ownership and minute assumptions remain
O-051. - Personalized medication-use support after clinician approval — core commitment when an approved regimen exists. Proxi identifies practical barriers, supports the person's chosen reminder or organization approach, prepares supply and packaging coordination, prompts teach-back, and monitors new concerns. It never creates, changes, or reconciles the regimen.
- Rapid-change recognition and human handoff — embedded core safety capability, not a standalone marketed service. Proxi preserves the observable baseline, makes reporting easy, captures what changed, and prepares the report for immediate authorized routing to a human responder and clinician. “Detection” must not imply diagnosis or automated triage.
- Wandering and missing-person preparedness — core when applicable, not universal. Proxi helps map patterns and likely destinations, maintain current contacts and identification information, assemble the human response plan, and support rehearsal. Human and clinical review is required for restrictions, environmental changes, autonomy concerns, and actual missing-person response.
Promise 3: Partner-enabled support for staying independent#
- Fall prevention — partner-enabled standard. Proxi can repeat approved questions, assemble records, prepare coordination of assessment, equipment, and referrals, and track completion. A clinician, PT, OT, pharmacist, or other qualified professional assesses risk and selects the intervention; people authorize and carry out the coordination.
- Early and recurring future planning — partner-enabled standard. Proxi can present an approved planning offer without pressure, elicit values, identify trusted supporters, prepare professional-conversation scheduling, organize completed documents, and prompt human review. Capacity, legal advice, medical counseling, and medical orders remain with qualified humans.
- Hearing and vision optimization — partner-enabled standard. Proxi can identify gaps, prepare visit scheduling, track devices and repairs, support daily routines, and carry accessibility needs into every contact. Sensory professionals diagnose, prescribe, fit, and assess effectiveness; people authorize and complete the external arrangements.
- Meaningful activity and social connection — partner-enabled standard. Proxi can learn identity and interests, find realistic options, identify practical barriers, and ask whether the person actually enjoyed and valued the activity. The beneficiary or caregiver chooses, human staff handle practical coordination, and community organizations furnish the activity; clinicians or therapists enter only when safety or therapeutic suitability requires them.
Later enhanced packages#
- Nutrition, hydration, and swallowing support — later package. Keep baseline screening, urgent response, and referral now. Do not market the full longitudinal package until reliable clinician, dietitian, dental, and speech-language-pathology coverage exists; aspiration, dehydration, and weight loss make false reassurance particularly dangerous.
- Functional independence and reablement — later package. Keep beneficiary goal capture, referral, and practical follow-through now. Do not promise a full reablement service until dependable OT or rehabilitation capacity exists, because the decisive assessment, plan, teaching, and outcome interpretation are professional services Proxi does not own.
This recommendation creates six core commitments, four partner-enabled standards, and two later packages. Each enhanced commitment remains inactive as a marketed promise until its O-052 activation gate is met. “Core” still means only when the service is applicable and accepted; it does not mean every beneficiary receives every intervention.
Minimum practical workforce#
| Workforce domain | Business responsibility | Boundary | Review |
|---|---|---|---|
| Beneficiary, caregiver, or authorized representative | Supply lived facts; express goals and preferences; choose participation and services; give or refuse consent; practice and report what happened. | Their action is not a Proxi output and cannot be inferred from silence. | |
| Proxi | Collect and organize; retrieve records; prepare source-labeled summaries; present approved questions and material; draft; schedule and remind; match and rank; prepare and track external communications; identify missing, conflicting, or concerning information. | Proxi does not determine eligibility, urgency, diagnosis, treatment, medication reconciliation, service choice, clinical suitability, or billability. Current V1 outbound PHI packets use an authorized human release; whether routine policy-approved transmissions become automatic is still open. | |
| Puerto Rico navigator and Philippines non-clinical staff | The $22/hour Puerto Rico navigator owns the relationship, qualifying contacts, nonclinical assessment and care-plan work, caregiver education/support, and sensitive coordination. The self-staffed Philippines team provides 24/7 first answer and administrative pursuit between calls. | The navigator holds current Alzheimer’s Association® essentiALZ® certification for dementia care navigation. Neither lane performs licensed clinical acts. | |
| Separate U.S. Proxi clinical team | Perform scheduled assessment pre-review and examination; interpret findings; determine risk and urgency; make treatment and referral decisions; reconcile medication; prescribe; create medical orders; review triggered concerns. | This workforce is outside the Puerto Rico navigator operation. The current base separates a beneficiary-location-authorized RN/LCSW pool from the dementia-proficient NP/PA/CNS/physician E/M or prescribing-clinician pool. Other specialists enter only when the act requires them. | |
| Program, compliance, quality, data, and billing | Own CMS submissions, notices, rosters, training evidence, partner oversight, privacy, reporting, audit support, claims, denials, and financial reconciliation. | Most of this work is human-required but not clinical. Approval and release authority cannot be inferred from administrative access. | |
| External partners | Furnish outside clinical care, pharmacy work, hospital or facility information, emergency response, community services, and specialty therapy. | External delay is not participant labor, but Proxi pursuit, exception handling, and failed handoffs are. The 24/7 first-answer roster is self-staffed rather than an external helpline service. |
How clinical capacity should enter#
| Clinical pattern | Current task types | Operating meaning | Review |
|---|---|---|---|
| Clinical judgment in every applicable occurrence | 52 | Schedule the qualified professional into the episode. Preparation can be delegated; the judgment cannot. | |
| Clinical review only on a defined trigger | 244 | Navigator or Proxi-supported routine work continues until a symptom, safety issue, contradiction, medical question, unreliable history, material change, or unresolved uncertainty appears. | |
| No clinical judgment in the task | 307 | Use Proxi, the beneficiary or caregiver, non-clinical staff, program staff, or an external party as required. A human may still be mandatory for relationship, choice, authority, or service delivery. |
These are task types, not encounters. Several task rows can occur in one conversation, and several trigger rows can converge on one clinical episode. A negative report is not a clinical finding of stability; scheduled assessments still occur, and uncertainty itself can require review.
Workload and staffing model#
Headcount should be built from business occurrences and active role-minutes, not from the number of task rows.
| Cadence | Planning units | Review |
|---|---|---|
| Entry and annual | Potential-patient intake; consent and alignment; initial or annual assessment; home visit; caregiver assessment; medication reconciliation; care plan; PAAF; CMS result; required notice. | |
| Scheduled recurring | Tier-based navigator contact; care-plan maintenance; caregiver education or coaching; medication-use follow-up; accepted enhanced-service session. | |
| Event-driven | Transition; symptom; fall; behavior concern; wandering event; medication discrepancy or change; referral; caregiver change; authority conflict; residence change; denial; external nonresponse. | |
| Standing availability | 24/7 human response; backup responder; clinical escalation route; primary navigator contact route. | |
| Back-office periodic | Monthly claim readiness and billing; denials; roster and partner maintenance; performance and care-delivery reporting; audit support; resource-inventory review. |
For each role:
Monthly role-minutes = the sum across planning-unit types of completed units of that type × observed active minutes for that role and unit type, plus retries, rework, fixed periodic work, and standing-coverage burden.
Role FTE = required productive role-minutes ÷ observed productive minutes available per staffed FTE.
Clinical demand must be calculated separately by trigger type and qualified role. Navigator demand must use actual GUIDE tier and caregiver mix, additional agreed contacts, unsuccessful attempts, and event-driven contacts. The 24/7 service needs a coverage and concurrency model even when call volume is low.
The first transparent estimate using this method is in 22_GUIDE_Human_Workload_and_Staffing_Estimates.md. It separates beneficiary reach, active case minutes, first-year add-ons, fixed program overhead, and standing 24/7 coverage rather than multiplying the 603 task count by a generic handling time.
Before estimating headcount, measure at least:
- aligned beneficiaries by tier, caregiver status, residence, geography, language, accessibility need, and accepted enhanced services;
- intake, alignment, annual assessment, reassessment, transfer, and unalignment volume;
- required and additional contacts, missed contacts, retries, modality, travel, and active minutes by role;
- transition, medication, referral, behavior, fall, wandering, caregiver-crisis, and other event incidence;
- the percentage and active minutes of routine work that reaches each type of clinician;
- 24/7 call arrival, reason, handling time, transfer rate, escalation rate, abandonment, and peak concurrency;
- external response time, attempts, manual-work rate, nonresponse, and staff pursuit time;
- PAAF, notice, claim, denial, correction, partner-change, reporting, and audit volumes;
- enhanced-service offer, acceptance, participation, discontinuation, and clinical-trigger rates;
- rework, reopened work, failed delivery, conflicting information, and work completed without adequate evidence;
- observed productive minutes available per staffed FTE after leave, training, supervision, meetings, breaks, and coverage constraints, with a consistent rule for whether documentation time is included in each planning unit.
Settled operating points#
- Sell one full Proxi-enabled GUIDE operating service covering all eight in-scope service domains; respite alone is excluded.
- Package enhanced care as three promises, with six core commitments, four partner-enabled standards, and two later packages.
- Use the five completion owners to build every operating SOP: Proxi, beneficiary/caregiver, non-clinical participant staff, participant clinician, or external party.
- Preserve the six workforce domains and the navigator-versus-administrative and clinician-versus-specialist boundaries.
- Estimate staffing only from observed occurrence volume and active role-minutes.
- Keep every public-RFA and participant-operation conclusion provisional until the missing controlling participant documents are reconciled.
- Give each beneficiary one primary person-facing contact owner, bundle applicable service work, reuse qualifying inbound interactions, require a named person-facing purpose and result before planned outreach, and never create a contact, clinical review, reconciliation, plan revision, or education event solely to fill a billing month.
The current human-workload estimate is in 22_GUIDE_Human_Workload_and_Staffing_Estimates.md. The next semantic pass should refine event incidence and role minutes from the first operating cohort rather than reopening the commercial scope. No implementation control layer is needed for that pass.