Workload and staffing estimates

Status: PROVISIONAL WORKFORCE MODEL — not a CMS time standard, staffing approval, or price. O-039 controls navigator episode mix and annual totals; O-045 controls mandatory specialist-review labor.
Date: 2026-07-12
Unit: One aligned GUIDE beneficiary-year, with established-year workload separated from first-year alignment work
Scope: Proxi is responsible for arranging and staffing every GUIDE service in scope except respite. Individual acts may be performed by Proxi employees, Proxi-contracted licensed professionals or partners, or required outside endpoints; the GUIDE Participant retains only accountability and acts that cannot legally or contractually be delegated.

Direct answer#

The human-in-the-loop model should not be one generic nurse reviewing everything. It should be a small number of distinct labor lanes:

1. Proxi fulfills all GUIDE services in scope except respite. The workload model no longer asks whether Proxi sells software, navigation, or clinical services separately. It assumes Proxi supplies or contracts every required human service while the GUIDE Participant retains only nondelegable accountability and external clinicians or organizations furnish acts only they can perform.
2. A Puerto Rico-based dementia care navigator touches 100% of aligned beneficiaries and absorbs the broad nonclinical human-service lane. The provisional planning input is 341 active minutes per established beneficiary-year: 302 minutes for required contacts, relationship, care-plan and navigation work plus 39 minutes for nonclinical caregiver education, coaching, facilitation, and support. O-039 controls approval or replacement from observed episode mix, preparation, documentation, and follow-through. The navigator is required to hold a current Alzheimer’s Association® essentiALZ® certification for dementia care navigation throughout each service year and is budgeted at $22 per hour all-inclusive.
3. The Philippines team self-staffs 24/7 first answer and performs interruptible administrative work between calls. At 5,000 covered lives, the base requires about 6.92 coverage FTE plus 0.5 FTE of team-lead/quality capacity, or 185 paid minutes per beneficiary-year after shrinkage, relief, and supervision. The 21 active VEA/admin minutes fit inside that paid coverage capacity and are not added again.
4. A Philippine RN without beneficiary-location authorization remains offshore nonclinical support for U.S. beneficiaries. The RN education may improve terminology capture, scripted history, teach-back, escalation-cue recognition, and quality review, but it does not create U.S. nursing authority or clinical triage authority.
5. The provisional split-team input assigns 74 minutes per established beneficiary-year to clinical support. That separate U.S., beneficiary-location-authorized pool contains about 60–65 RN minutes and 7–10 portfolio-average LCSW or behavioral-clinician minutes. None of these minutes is Puerto Rico navigator labor.
6. GUIDE still requires a separate dementia-proficient Medicare clinician. The revised higher-authority U.S. clinical pool is 106 minutes per established beneficiary-year for annual cognition examination, medical decision-making, staging and synthesis, medication reconciliation, diagnosis/treatment decisions, and triggered clinical events. The minimum team role is a Medicare Part B E/M-eligible physician, NP, PA, or CNS meeting dementia-proficiency requirements; a regular RN alone does not satisfy it. This pool is also outside the Puerto Rico navigator operation.
7. There is no valid single established-year subtotal until the shared-coverage panel size is named. Every shared pool must use the same actual aligned-life denominator. Under the provisional inputs, the established-year total is approximately 2,413 minutes at 500 lives, 1,469 at 1,000, 903 at 2,500, and 714 at 5,000 before mandatory per-occurrence review and other exclusions. The navigator layer remains subject to O-039. These are staffing hypotheses, not CMS time standards or field observations.

The model deliberately routes every permissible nonclinical act to the $22 Puerto Rico navigator or the self-staffed Philippines team before using the more expensive, separate U.S. beneficiary-location-authorized clinical pools. Puerto Rico performs none of the clinical or medical work in this staffing design.

No clinical or caregiver-service domain is left as optional Participant-supplied labor. Proxi supplies or contracts the navigator, caregiver-service, RN/LCSW, higher-clinician, local-home-visit, program, compliance, billing, and 24/7 labor needed for the non-respite service. The Participant retains only legally or contractually nondelegable accountability, approvals, attestations, signatures, CMS relationships, and oversight. Outside PCPs, specialists, pharmacies, hospitals, emergency authorities, and community organizations remain responsible for their own endpoint acts; Proxi owns the required coordination around them.

What the percentages mean#

Three different percentages must remain separate:

The calculation for an event-driven role is:

Expected annual active minutes = beneficiary reach × events among reached beneficiaries × active minutes per event.

Scheduled navigator contacts and annual clinical work are added directly because they are not optional event incidence. Fixed program work and 24/7 availability are allocated separately so they are not confused with case interaction time.

One actual human event is counted once even when its evidence supports several GUIDE service obligations. For example, one clinical medication review may update Medication Management, Care Coordination, and the Care Plan, but its minutes are not charged three times; the single event record is linked to every applicable service. The same rule applies to one administrative pursuit episode or one qualifying contact that also contains separately evidenced caregiver support.

Service credit is not a second unit of labor. CMS does not prescribe a separate number of minutes for each service, so one conversation may furnish several obligations without making the caregiver repeat it. But CMS still requires an actual care-delivery service in a billed month: infrastructure alone, a social-only or undocumented contact that does not perform the required touchpoint work, a service mention, or an opened downstream task receives no additional credit. A substantive required contact with a documented no-change outcome may qualify. Each credited service needs its own content/evidence link, and the patient-month still produces only the applicable DCMP claim rather than one claim per credited service.

Role and geography boundary#

The verified official credential wording is Alzheimer’s Association® essentiALZ® certification for dementia care navigation. The issuer's current page says the full Dementia Care Navigation Training Series with certification meets GUIDE training requirements and that the credential is valid for two years. Proxi should require the credential to remain current throughout every service year and separately maintain the annual GUIDE training evidence. The curriculum supports broad nonclinical dementia-navigation capability but does not confer RN, social-work, prescribing, diagnostic, treatment, or Medicare billing authority.

Settled staffing design for this estimate#

1. Proxi maintains, staffs, and furnishes all eight GUIDE service domains in scope as applicable to each beneficiary's and caregiver's needs; respite alone is excluded. This is full-package capability and ownership, not a requirement that every beneficiary receive every domain every month.
2. The default recurring role is a Puerto Rico-based, nonclinical dementia care navigator with current Alzheimer’s Association® essentiALZ® certification for dementia care navigation, budgeted at $22/hour all-inclusive.
3. The navigator performs every permissible nonclinical human act, including caregiver education and support, before work is routed to a separate U.S. licensed-clinician pool. The Puerto Rico operation performs no clinical or medical act.
4. The Philippines team self-staffs 24/7 first answer and absorbs ordinary VEA/admin exceptions during available capacity; neither Philippine licensure nor employment location creates U.S. clinical authority.
5. The separate U.S., beneficiary-location-authorized RN/LCSW pool performs annual split-team clinical pre-review plus triggered clinical, behavioral, transition, medication-use, safety, and caregiver-distress review.
6. The separate U.S. dementia-proficient Part B E/M and prescribing-authority clinician pool retains the higher-authority clinical acts. Every professional must meet the applicable Medicare, roster, proficiency, scope, and beneficiary-location requirements; the pool is not sourced from the Puerto Rico navigator operation.

CMS-fixed navigator frequency#

The GUIDE RFA ↗ establishes the human navigator and the original tier cadence. The current PY 2026 Payment Methodology Paper ↗ adds the RCC tier and its bimonthly contact rule effective July 1, 2026.

The qualifying interaction may be in person, by telephone, or audio-visual. SMS and automated conversation do not satisfy the public-RFA minimum. Software and AI should prepare the navigator, supply context and prompts, and draft the note; the human time estimate below is the actual interaction plus human-only relationship or exception work.

The annual figures are arithmetic planning equivalents, not bankable annual quotas. CMS says the cadence is based on calendar months and resets after each touchpoint; clustered contacts do not substitute for a later quarterly, bimonthly, monthly, or twice-monthly window.

Navigator minutes by tier#

The low/base/high minutes below are provisional planning inputs, not an approved value-first workload estimate. Each tier total includes:

• required qualifying contacts;
• one annual human care-plan/relationship review; and
• an allowance for relationship-sensitive exceptions beyond the minimum contacts.

The scenario totals are reproducible from these assumptions:

The illustrative mix is not CMS data and is not an assertion about Proxi's future caseload. It exists only to produce a first portfolio average. Until actual tier mix is available, staffing should be recalculated directly from the tier rows rather than relying on 302 minutes.

The base contact assumptions are 20 minutes for low/moderate dyad, low individual, and RCC contacts and 25 minutes for high dyad and moderate/high individual contacts. The base annual relationship/care-plan allowance is 45 minutes. Base additional exception allowance ranges from 15 to 60 minutes by tier.

These figures cannot cap or stand in for the newer 8 / 15 / 25 direct-interaction bands. For each actual L2 episode, total active minutes include the direct conversation, pre-contact review, post-contact documentation, actual L2 follow-through, and retries or rework that genuinely consume L2 time. Shared minutes are counted once when one interaction furnishes several services; later distinct work is added once under the service actually performed. A corrected portfolio total requires the actual mix of stable, ordinary, extended, and focused-second-contact episodes under O-039.

Established-year human involvement#

This table carries the provisional planning inputs into the full-service role split. “Base reach” is the percentage expected to touch the role at least once during an established beneficiary-year. “Minute share” uses 550 active service-demand minutes and excludes fixed program overhead and unused standing-coverage time. The paid-labor total later removes active Philippines work already absorbed by the self-staffed coverage roster. The navigator total and every dependent subtotal remain provisional under O-039.

The Philippine RN is not an additional mandatory row. If Proxi uses a Philippine RN as a first-answer specialist or quality lead, the person absorbs part of the 185-minute Philippines coverage allocation. The Philippine credential still does not authorize U.S. nursing, and current D-005 continues to exclude Philippine calls from formal navigator-contact credit.

The 74 reviewer minutes and 106 higher-clinician minutes are distinct linked role touches. The lower-cost pool performs about 35 minutes of annual structured clinical/psychosocial pre-review plus event work; the higher-authority clinician performs examination, medical decision-making, synthesis, reconciliation, and decisions reserved to that role. The 39-minute nonclinical caregiver-service allowance is part of the Puerto Rico navigator's 341 minutes and covers the portfolio of training, facilitation, diagnosis-information, and support work. It includes only caregiver work incremental to an already-counted contact; when caregiver support or coaching is furnished inside that contact, the same L2 minutes are not booked again to the allowance. Inside it, the settled software-led skills-training route uses one 5 / 10 / 20-minute low / typical / high L2 application touchpoint, preferably within an existing qualifying contact when the actual service content is delivered and separately evidenced. The entry-only dementia-diagnosis conversation remains in the first-year add-on.

*The 662-minute navigator high contains a 207-minute caregiver/relationship residual above the 455-minute tier-contact high, while the 232-minute low contains a matching 10-minute residual above the 222-minute tier-contact low. Neither residual is yet decomposed into reproducible incidence and per-event assumptions. This row must not be used for pricing or staffing approval until O-039 replaces or explains it.

Clinical workload across all non-respite GUIDE services#

The 74-minute clinical-support pool is not one care-coordination review. It is the portfolio sum across assessment, monitoring, transitions, medication, caregiver/behavioral needs, safeguarding, care-plan changes, and 24/7 escalation:

In the base clinical-support pool, approximately 60–65 minutes are expected to be beneficiary-location-authorized RN work and 7–10 minutes are portfolio-average LCSW or behavioral-clinician work. The LCSW is event-driven; the pool reaches 100% because an authorized lower-cost clinician performs the annual pre-review. If Proxi removes that split-team pre-review, the annual minutes must move to the higher-authority clinician rather than disappearing.

Care Plan clinical labor attribution#

Care Plan clinical minutes count only renewed clinical judgment required by the plan. Clinical work already performed during the comprehensive assessment, medication reconciliation, transition review, behavioral episode, or another clinical event remains charged to that originating event even when its authorized result is incorporated into the Care Plan. The Care Plan receives service attribution for the incorporated content without duplicating the paid minutes.

Zero incremental Care Plan clinical minutes means that all required clinical content is current, attributable, within scope, and sufficient for faithful incorporation. It does not mean that the beneficiary had no clinical work. A new clinical fact, unresolved question, changed recommendation, stale applicability, conflicting instruction, or requested clinical alternative creates a new scoped contribution.

One clinician's contribution does not approve the whole plan. Multi-clinician cases retain separate attributable contributions and include the clinical work required to resolve or preserve disagreement. A Participant-authorized Care Plan owner then confirms plan-level completeness without exercising clinical authority the person does not possess.

The existing Care Plan row is a preliminary portfolio allowance, not an observed incidence model. Before it is replaced, owner calibration must state mutually exclusive no-new-clinician, one-L3, one-L4/treating-clinician, behavioral, and multi-clinician case shares; per-contributor active review and documentation minutes; and the incidence of clinical disagreement. The resulting minutes must be added to the appropriate clinical pool only when they were not already counted in the originating assessment, medication, transition, behavioral, or coordination episode.

The starter calibration below is a Proxi planning assumption, not a CMS rule, clinical standard, or field observation. It gives the preliminary row an auditable explanation that can be replaced with first-cohort data:

In addition, assume 0.15 plan-owned clinical questions per beneficiary-year between annual plan events: 60% RN/LCSW-scope at 6 minutes and 40% higher-authority at 12 minutes. These are questions created by care-planning work itself, not the clinical content of an assessment, medication, transition, behavioral, contact-trigger, or other already-open clinical episode.

The arithmetic produces about 2.8 RN/LCSW minutes and 2.9 higher-authority minutes per beneficiary-year, close to the current preliminary row's 3.0 and 3.2 minutes after rounding. It also implies about 0.65 scoped clinical contributions and 0.10 multi-clinician Care Plan events per beneficiary-year. For calibration, test a low-demand case with 75% zero-incremental annual events and 0.05 between-event questions, and a high-demand case with 35% zero-incremental annual events and 0.50 between-event questions; use 4–10 minutes for an RN/LCSW contribution and 8–15 minutes for a higher-authority contribution.

These figures are derived assumptions, not an independent time allowance. Changing the incidence, role mix, or per-contribution time must change the Care Plan row. A clinician touch is booked to exactly one clinical event family: care-plan-linked medication, transition, behavioral, contact-trigger, or other clinical work stays in its originating family and is linked to the plan without re-booking the paid minutes.

Pooled labor that case minutes miss#

24/7 human availability#

CMS requires human access for 100% of beneficiaries even though the base estimate assumes only 25% place a call in a year. Proxi's settled design is a Philippines-based self-staffed human first-answer team with Puerto Rico nonclinical care-team support and escalation to a separate U.S. beneficiary-location-authorized clinical workforce. The raw clock time of one seat is not the paid staffing requirement; shrinkage, relief, backup, and team-lead/quality capacity must be included.

Paid coverage allocation per beneficiary = paid coverage and relief FTE × 124,800 paid minutes per FTE-year ÷ covered aligned lives.

The base roster is 6.92 coverage FTE after shrinkage and relief plus 0.5 FTE of team-lead/quality capacity. At base call demand, approximately 1,875 calls per year consume about 3.6% of the primary seat. The same cross-trained team can therefore perform the 21 active VEA/admin minutes between calls while one person remains immediately answerable. Neither the admin work nor the approximately 4 active first-answer call minutes are added again to paid labor.

The displayed low and high paid-FTE values are scenario assumptions, not yet derivable from the stated shrinkage and relief percentages alone. On the manual's calendar-year minute basis, those percentages plus the 0.5 lead produce approximately 6.68 FTE at low and 8.28 FTE at high; the displayed 6.48 and 11.37 therefore require a separate documented concurrency, seat, or staffing derivation. Until O-039 and O-060 approve that derivation, neither bound may anchor a commercial quote.

The self-staffed roster is a pooled Proxi capability with a strong scale effect:

Approximately 4,630 covered lives are needed to keep the allocation below 200 minutes per beneficiary-year. Launch pricing must therefore use the lives actually sharing the roster, not assume the 5,000-life denominator before that scale exists.

A Philippine VA or Philippine-licensed RN may provide approved nonclinical first answer, identity/callback capture, verbatim concern capture, approved program information, protocol-driven emergency or clinical-route invocation, warm transfer, and documentation. They do not triage, determine urgency, practice U.S. nursing, reconcile medication, recommend treatment, provide the formal GUIDE navigator contact, or automatically satisfy the separate care-team-only substantive caregiver-support call. Activation still requires the executed Participation Agreement, approved Partner Organization arrangement, offshore-PHI posture, and immediate escalation design.

Program and compliance overhead#

The base model allocates 300 annual program/compliance hours across a 500-beneficiary Participant panel:

18,000 annual minutes ÷ 500 aligned lives = 36 minutes per beneficiary-year.

This covers roster governance, training evidence, annual reporting, policy maintenance, partner oversight, quality review, and audit readiness. It excludes the ordinary beneficiary-level exceptions represented by the separate 4-minute case allowance, and it does not include a major audit, dispute, corrective-action plan, contract negotiation, or claims crisis. The denominator must be changed to the actual aligned panel and actual overhead hours.

The review model now has three separate labor buckets:

The third bucket cannot be assumed to be either zero or universal. Some act classes may require a subject-matter person every time; others should use an approved clean path and escalate only exceptions.

Panel-size-specific Proxi full-service subtotal#

Proxi's settled offer is one full GUIDE service, excluding respite. There is no software-only or customer-clinician package in this workload denominator. A valid subtotal must use one covered-life denominator for every shared pool. A 746.2-minute mixed-denominator figure is invalid because it combines a 5,000-life Philippines allocation with a 500-life program-overhead allocation.

Under those assumptions:

Established-year minutes per beneficiary = 525 + (Philippines roster minutes + fixed program minutes) / actual shared panel lives.

*The known-role floor prices the current Puerto Rico, U.S. clinical, and Philippines rows only. It excludes program/compliance rates, mandatory per-occurrence review under O-045, local home-visit labor, physician medical-director overhead, payroll differences, enhanced-service labor not yet activated, and margin. The 341-minute navigator input remains provisional; every row must be recalculated if O-039 replaces it.

The pooled 5,000- and 10,000-life cells are mechanical illustrations of the same-denominator formula, not approved capacity or price points. The Philippines allocation cannot fall below the active work it absorbs—currently about 25 active minutes per beneficiary-year—plus a concurrency-tested 24/7 roster. The current 18,000-minute program-overhead assumption was estimated at 500 lives and cannot be divided toward zero indefinitely; reporting, roster, audit, denial, and partner work must be re-estimated at each launch panel. In particular, the 10,000-life Philippines cell and the 5,000/10,000-life program cells require panel-specific demand and concurrency estimates before commercial use.

Boundaries already resolved in the component model#

• The 185.2-minute self-staffed Philippines allocation applies only at the 5,000-life denominator. At every panel size, the allocation includes paid shrinkage, relief, team-lead/quality capacity, active VEA/admin demand, and active first-answer calls; none is added twice.
• The 150 first-year navigator minutes are incremental beyond the established-year relationship and exception allowances and exclude the separately estimated home visit and diagnosis-information conversation.
• The 74-minute lower-cost clinical-support pool and 106-minute higher-authority clinician pool represent different linked work; if both roles touch one event, their actual times are recorded separately.
• The 36-minute fixed program allocation applies only at the 500-life denominator. At other panel sizes, divide the current 18,000-minute assumption by the same lives used for the Philippines pool. The fixed allocation excludes the ordinary beneficiary-level exceptions represented by the 4-minute case allowance.
• Clinical transfer time from the 24/7 line is already included in the reviewer and higher-clinician event budgets; substantive nonclinical caregiver support is already included in the Puerto Rico navigator budget.
• A clinician touch belongs to exactly one clinical event family. Care-plan-linked transition, medication, contact-trigger, and behavioral touches remain in their originating family and are linked to the Care Plan without re-booking the minutes.

The panel table makes the provisional arithmetic reproducible at one denominator at a time. It does not settle the value-first navigator workload, the correct scale curve for program overhead, or the actual coverage roster at launch. O-039 must approve or replace the contact mix, preparation, documentation, follow-through, and focused-second-contact assumptions before any displayed subtotal is used for staffing or pricing approval.

First-year alignment add-on#

Newly aligned beneficiaries require more human work than established beneficiaries. The current CMS payment methodology ↗ also distinguishes new-patient payment during the first six months, but CMS does not specify these labor minutes.

The Puerto Rico navigator carries about 501 provisional minutes in the first beneficiary-year: 341 established-year minutes, 150 entry/relationship minutes, and 10 diagnosis-information minutes. Add the 255-minute first-year increment to the applicable panel-size subtotal. That produces approximately 2,668 / 1,724 / 1,158 / 969 / 874 minutes at 500 / 1,000 / 2,500 / 5,000 / 10,000 lives, respectively, before O-039, O-045, and the other stated exclusions. If the local RN reviewer performs the home visit, transfer the expected 30 minutes to that role rather than adding it twice. Travel and mileage remain excluded and must be priced by geography.

What each candidate workforce actually replaces#

Philippine VA#

• Expected base reach: 60%.
• Expected base active time: about 21 minutes per beneficiary-year.
• Self-staffs the first-answer 24/7 lane and performs manual administrative work between calls while answerability is protected.
• The 21 active admin minutes are demand, not an additional paid allocation beyond the 185.2-minute coverage pool.
• Does not conduct required navigator contacts or clinical work under the current operating rule.

Philippine RN#

The Philippine RN is a higher-capability member of the same Philippines first-answer/admin pool. The person may improve terminology capture, scripted history, approved teach-back, escalation-cue recognition, and call-quality coaching. The person may not triage, determine urgency, perform a U.S. nursing assessment, interpret symptoms or medication effects, reconcile medication, recommend treatment, prescribe, issue orders, replace the beneficiary-location-authorized clinician, or satisfy the Part B dementia-proficient clinician role.

Puerto Rico dementia care navigator#

• Puerto Rico is a U.S. territory and is included as a “State” for HIPAA purposes, but it remains a distinct professional-licensing jurisdiction.
• Required credential: current Alzheimer’s Association® essentiALZ® certification for dementia care navigation, documented by issue and expiration dates. The issuer states that certification is valid for two years; Proxi requires it to remain current throughout every service year.
• Expected reach: 100%.
• Established-year base: 341 minutes per beneficiary; first-year base: approximately 501 minutes.
• Planning rate: $22/hour all-inclusive, producing about $125.03 annual or $10.42 PMPM established-year navigator cost.
• Scope includes every permissible nonclinical human GUIDE act covered by training and policy: qualifying contacts, nonclinical assessment domains, care-plan facilitation, caregiver education/coaching/support, transitions logistics, community-service coordination, approved behavior and safety education, and practical medication-use support.
• The navigator separately completes any required annual GUIDE training and maintains the Participant's training evidence.
• Does not need an RN license merely to navigate.
• Does not gain diagnosis, treatment, prescribing, nursing, social-work, clinical-triage, medication-reconciliation, or Medicare billing authority from the certification.

Puerto Rico RN assigned to the navigator operation#

• May perform exactly the same nonclinical navigator work after GUIDE training.
• The RN license is economically optional because the assigned work remains nonclinical.
• Proxi does not use the Puerto Rico navigator operation for nursing assessments, clinical triage, medication reconciliation, diagnosis, treatment, prescribing, or other clinical or medical work, even when an individual navigator separately holds an RN or other professional credential.
• Every clinical question transfers to the separate U.S. clinical workforce. A regular RN in any location still does not replace the required dementia-proficient Part B E/M clinician.

U.S.-authorized medical professional#

The minimum GUIDE clinical role should be named dementia-proficient Part B E/M clinician, not simply “U.S. medical person.” A physician/MD, NP, PA, or CNS may fill it when the person meets dementia-proficiency, Medicare enrollment/roster, billing-relationship, and patient-location authorization requirements. In Proxi's staffing design this professional belongs to the separate U.S. clinical workforce, not the Puerto Rico navigator operation.

The full-service base assigns 74 minutes to the lower-cost separate U.S. beneficiary-location-authorized clinical-support pool and 106 minutes to the separate U.S. higher-authority E/M/prescribing-clinician pool. These are Proxi-supplied or Proxi-contracted service costs; they are no longer modeled as optional customer labor and none is Puerto Rico navigator labor.

Capacity implication#

At 70% productive utilization, a 160-hour month contains 6,720 productive minutes.

These are arithmetic ceilings, not recommended caseload promises. A first pilot should plan approximately 125–150 all-new beneficiaries or 150–200 established beneficiaries per full-time navigator, with a blended launch target around 140–160, until actual missed-contact attempts, additional contacts, leave, supervision, meetings, event spikes, documentation time, and language/accessibility effects are measured. CMS does not publish a navigator caseload limit.

Navigator workforce training adds 20 hours once at onboarding and 2 hours annually per navigator. It is workforce overhead rather than a beneficiary interaction. At a 200-beneficiary panel, the recurring 2-hour annual training allocation is 0.6 minutes per beneficiary-year; onboarding and turnover require a separate hiring assumption.

What is not yet in the estimate#

• Travel, mileage, and local scheduling burden for in-person home visits.
• Part-time physician medical-director overhead when the dementia-proficient clinician is not a physician.
• Observed 24/7 arrival distribution, concurrent-call demand, language mix, answer time, abandonment, and the actual Philippines team-lead wage premium; the current model includes base shrinkage, relief, flex backup, and 0.5 FTE of team-lead/quality capacity.
• Actual tier and caregiver mix.
• Missed-contact attempts and no-show time.
• Multilingual contact duration and interpreter cost.
• Customer-specific clinical documentation burden beyond the Proxi full-service base.
• A major transition, hospitalization, wandering event, caregiver crisis, medication crisis, audit, dispute, or corrective-action plan beyond the event ranges.
• Participant-only nondelegable acts and any unpriced program/compliance role rates.
• Mandatory per-occurrence privacy, compliance, legal, billing, or program review until the O-045 act matrix supplies incidence, minutes, role, and rate.
• Margin and wage deviations from the current $5.50/$22/$64/$140 planning rates.

Calibration data needed from the first operating cohort#

For each completed human episode, capture only the facts needed to replace assumptions:

• beneficiary tier, caregiver status, residence type, and whether this is the first six months;
• human role and supplying organization;
• episode type and whether it was scheduled, event-driven, failed-automation, or standing coverage;
• active minutes, documentation minutes, unsuccessful-attempt minutes, and travel minutes separately;
• whether the episode resolved, escalated, transferred, or reopened;
• clinical destination and license/jurisdiction when clinical work occurred;
• whether a caregiver service was offered, accepted, attended, or declined.

After 90 days or the first 100 aligned beneficiaries, whichever produces a more stable sample, replace each reach rate, event frequency, and minutes-per-event assumption with observed median, 75th percentile, and 90th percentile values. Do not use task counts as a substitute for this measurement.

Source and decision boundary#

Public-source anchors:

• CMS GUIDE Request for Applications ↗, especially care-team requirements and training at PDF pp. 25–27 and Appendix B §§1, 3, 4, 7, and 8.
• CMS GUIDE Payment Methodology Paper v3.0 ↗, especially current tiers, RCC cadence, Partner Organizations, and billing context.
• CMS GUIDE FAQ ↗, especially virtual-service and in-person home-visit guidance.
• HHS cross-state telehealth licensing ↗.
• Nurse Licensure Compact current map ↗.
• Puerto Rico Board of Nurse Examiners ↗ and Puerto Rico telemedicine/telesalud certification ↗.
• HHS overseas ePHI guidance ↗.
• Alzheimer’s Association Dementia Care Navigation Training ↗ and published learning objectives ↗.

Still controlling the unresolved design:

• D-005: Philippine calls do not currently satisfy required GUIDE navigator contact.
• O-001: exact permitted offshore activity under the executed Participation Agreement and CMS interpretation.
• D-012: Proxi's commercial service fulfills all in-scope GUIDE services except respite.
• D-013: Puerto Rico navigator credential, scope, and $22/hour all-inclusive rate.
• D-014: self-staffed Philippines 24/7 first-answer design.
• D-015: Puerto Rico performs no clinical or medical work; all such work routes to the separate U.S. clinical workforce.
• O-028: exact credential, jurisdiction, and scope taxonomy for clinical and medication work.
• O-039: acceptance or replacement of this estimate's tier mix, reach, event-frequency, contact-minute, coverage-pool, and program-overhead assumptions.
• O-060: commercial treatment of pooled 24/7 coverage and program overhead at sub-scale panels, including the actual shared-life denominator and concurrency thresholds.

The executed Participation Agreement and CMS-approved Partner Organization arrangement remain necessary before Proxi promises that an offshore employee or any particular subcontractor can deliver a required GUIDE care-delivery service.