How a U.S.-Based Community Clinic Reduced Patient No-Shows by Addressing Social Barriers With Pillar

A U.S.-based community clinic partnered with Pillar by SocialRoots.ai to reduce persistent patient no-shows by making Social Determinants of Health (SDOH) visible, actionable, and measurable—directly within everyday care workflows. By embedding SDOH screening and care coordination alongside existing EHR systems, the clinic improved appointment adherence, care continuity, and patient outcomes without increasing documentation burden for staff.

Key Takeaways

With Pillar in place, the clinic was able to:

• Identify transportation and access barriers impacting appointment attendance
• Embed SDOH screening directly into routine clinical workflows
• Connect social risks to actionable care plans and follow-ups
• Reduce missed appointments through proactive, targeted interventions
• Gain real-time visibility into SDOH-driven outcomes and trends

Background

The clinic serves a diverse U.S. patient population, including Medicaid beneficiaries and uninsured individuals managing chronic and behavioral health conditions. Care coordination teams oversee patient engagement and follow-up across multiple programs.

Despite delivering high-quality clinical care, the clinic faced frequent missed appointments—particularly for follow-up and chronic care visits. These no-shows disrupted continuity of care and strained already limited care coordination resources.

Care teams suspected social barriers were a primary driver but lacked a consistent way to document, track, and act on them.

Addressing Social Drivers of Care

Transportation challenges, housing instability, and work constraints regularly surfaced during patient visits. However, this information was captured inconsistently—often buried in free-text notes or informal conversations.

Without structured SDOH data:

• Care teams could not identify high-risk patients early
• Interventions remained reactive rather than proactive
• Leadership lacked insight into why no-shows occurred
• Reporting for quality and value-based programs required manual effort

The clinic needed a way to operationalize SDOH as part of care delivery, not as a separate process.

The Challenge

• Persistent no-show rates impacting outcomes and reimbursement
• No standardized method for capturing social risk factors
• Manual follow-ups that varied by staff and program
• Limited visibility into which interventions were effective
• Replacing the existing EHR was not an option

Why Pillar

Clinic leadership selected Pillar by SocialRoots.ai because it goes beyond referrals or static resource lists.

Unlike point solutions, Pillar embeds SDOH data directly into care management workflows—linking social risks to care plans, encounters, and outcomes within a centralized platform.

Key decision factors included Pillar's ability to:

• Embed structured SDOH data collection into clinical workflows
• Link social risks directly to personalized care plans and interventions
• Track outreach and follow-ups using standardized encounter notes
• Provide real-time insights without manual reporting or spreadsheets
• Integrate with existing EHR systems without disruption

Solution

Pillar was integrated with the clinic's existing EHR and configured to support SDOH-focused care coordination within weeks.

Custom intake and follow-up forms captured structured social risk data. Patients identified as high risk were automatically flagged and connected to personalized care plans, enabling care navigators to intervene earlier and more consistently.

Implementation followed a phased approach aligned with existing workflows, ensuring rapid staff adoption.

Pillar in Action

SDOH Screening

Embedded into intake and follow-up encounters.

Personalized Care Plans

Transportation and access interventions assigned to care navigators.

Encounter Notes

Standardized documentation of outreach and patient engagement.

Analytics Dashboards

Real-time tracking of no-show trends and intervention outcomes.

Impact

Since implementing Pillar, the clinic has:

• Reduced missed appointments among high-risk patients by double digits
• Improved follow-up adherence for chronic and behavioral health visits
• Decreased manual outreach effort for care coordinators
• Gained real-time visibility into which social interventions drive results
• Strengthened documentation for quality reporting and value-based programs

"We finally understand why patients miss appointments—and what actually helps."

What was once reactive follow-up is now a proactive, data-driven care process—without adding burden to already stretched care teams.

Lessons Learned

Addressing social barriers is essential to improving access, continuity, and outcomes. When SDOH data is embedded into everyday care workflows—not siloed in separate tools—care teams can intervene earlier, allocate resources more effectively, and deliver more equitable care.

Ready to Reduce No-Shows and Improve Care Continuity?

Pillar by SocialRoots.ai helps healthcare organizations operationalize SDOH, strengthen care coordination, and gain real-time insight—without replacing existing EHR systems.