FQHC Improves Performance Across All Service Lines
SDOH-aware workflows and proactive outreach close care gaps in underserved populations.
61%
Performance improvement
42%
More patients served
91%
Patient retention
4 mo
Time to results
The Challenge
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.
The Solution
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.
The Results
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.
“Partnering with Guideway Care for after-hours nurse triage transformed our patient flow. We saw a significant drop in non-emergent ER visits within the first 6 months, and our patient satisfaction scores reached an all-time high.”