A Federally Qualified Health Center serving a predominantly underserved population faced compounding barriers to patient follow-through: transportation gaps, language barriers, financial stress, and food insecurity. Despite best efforts, care gaps remained stubbornly open and quality metrics lagged behind targets.

Guideway Care deployed SDOH-aware Activation Care Guides who used the Stressor Inventory process to surface non-clinical barriers during every patient interaction. Workflows were built around the community’s specific needs — multilingual outreach, transportation coordination, benefits enrollment assistance, and proactive appointment scheduling integrated with the FQHC’s EHR.

Within 4 months, overall performance improved by 61% across all service lines. The center served 42% more patients year-over-year without adding clinical staff. Patient retention reached 91%, and the center exceeded all UDS quality reporting benchmarks for the first time in its history.