How CHCs and Yuvo Health partner to keep patients like Joe out of the hospital

Community health centers (CHCs) are on the front lines of managing complex patient needs. Yet the system often sets them up to fail. Despite their best efforts, health centers can be penalized for circumstances beyond their control — delayed hospital data, disconnected patients and chronic conditions that spiral out of control.

Take Joe (a hypothetical patient). He’s 47, lives alone, and struggles to manage his diabetes. Some months are tougher than others. When his blood sugar drops too low, Joe faints or has seizures, and his only option is to go to the Emergency Department (ED).

In just one year, Joe experienced three ED visits for fainting and seizures, two hospitalizations for diabetes complications and his phone was disconnected three times when he couldn’t pay his bill. 

The health center wants to help, but their hands are tied. 

The health center’s challenge

Although the health center has Joe down as an attributed patient, the care team often feels like they’re working in the dark. They want to help Joe, but roadblocks keep getting in the way:

• Data delays mean they don’t learn about Joe’s ED visits until weeks later.
  
• No timely notifications means they miss the chance to support him after discharge.
  
• Unmanaged chronic illness raises the risk of readmission.
  
• Open care gaps drag down the health center’s HEDIS scores.

Behind the scenes, health center staff face the daily frustration of trying to track down Joe. They call, but enough time has passed that his number is no longer active. They want to educate him, encourage him, connect him to resources — but without the right tools, they’re stuck trying to reactively manage crises instead of working with Joe to prevent them.

Joe’s story isn’t unique. It’s a glimpse into the daily frustrations faced by health centers nationwide. But Yuvo Health and CHCs have partnered to flip the script. 

The Yuvo Health partnership: closing care gaps

By partnering with CHCs, Yuvo provides the hands-on support and real-time insights needed to care for patients like Joe. 

With Yuvo Health, CHCs get:

• Hospitalization notifications within hours — not weeks.
• Care coordination and patient engagement — the Yuvo team reaches out to patients like Joe within 24 hours.
• Access to a complete health history before the patient even arrives for a visit.
• Patient empowerment tools — such as educational materials to help Joe manage his diabetes and avoid unnecessary ED visits.

One year later: patient care and CHC performance soar

The results speak for themselves.

One year later, Joe’s health is back on track. His A1C has decreased and his overall health improved. He has had no ED visits because he calls his CHC first instead of heading straight to the hospital. And the health center gets credit for the work involved in caring for Joe:

Because Joe has the care he needs, the health center doesn’t just avoid crises — they see real, measurable gains that strengthen both performance and morale:

• Care gaps close, and the health center gets credit for the work they do
• Risk scores and compensation increase
• Quality scores rise
• Utilization and costs decrease

Joe’s story is more than one patient’s journey — it’s a reflection of how equipping health centers with the right tools transforms care. Patients get healthier. Staff frustrations ease. Performance improves.

The impact at scale

Joe’s journey is powerful, but the real transformation happens when we step back and look at how the model affects health centers across the entire Yuvo Health network.

Joe’s results aren’t just anecdotal. Across the Yuvo network, CHC partners have seen meaningful reductions in unnecessary utilization, including a 16% drop in overall ED use, a 14% decrease in potentially preventable emergency department (ED) usage, and a 29% reduction in inpatient visits, according to 2023 - 2024 data from our Fidelis VBC arrangement.

We are proud to shoulder the administrative burden so health centers can focus on what matters most — delivering care. By taking on the heavy lift of tasks like data management and patient outreach, we free up CHC teams to do their best work.

Here is a glimpse at how the Yuvo team supports CHC partners:

• 3,500+ patients reached across 12,000 targeted call or text outreach attempts
  
• 8,000+ chart audits completed
  
• Continuous data pulls from HIEs, EHRs, ADT feeds, and more
  
• Yuvo Master Patient Index (YMPI) identifying attributed patients with precision
  
• 80+ provider trainings delivered to optimize workflows and use of tools
  
• “Call Us First” materials deployed network-wide to guide patients toward their CHCs

When Joe’s result is multiplied across 200,000 patients at ten health centers, the result is a stronger, more connected system of care. Health centers are no longer held back by administrative burdens — they’re empowered to build relationships, close care gaps and help every “Joe” thrive. 

The best part? Getting the tools and support to drive quality improvement is only a portion of the value health centers receive from a partnership with Yuvo Health. It all builds toward a more sustainable future through value-based care, where health centers can be there for everyone in their communities. 

Driving success in value-based care

The same supports that helped Joe are the foundation for enabling health centers to succeed in value-based care arrangements.

Community health centers already deliver comprehensive, preventive care at lower costs—an approach that aligns directly with value-based care. On average, CHCs generate a 24% savings in health care costs per Medicaid patient compared to other providers. Through value-based care, health centers have the opportunity to earn their share of these savings. 

Historically, value-based care has proven out of reach for health centers, but Yuvo Health is changing this. With Yuvo, health centers can now access more meaningful value-based contracts while Yuvo shoulders the risk, gain a team of population health experts backed by streamlined technology and do so within a program uniquely tailored to them. 

At Yuvo, we're committed to supporting community health centers, because they are the key drivers of health in the communities many of us have called home.

"As a former patient of an FQHC, I'm forever grateful for the care, support and dignity shown to my family, regardless of our insurance status. Through Yuvo Health, we're supporting health centers so they can provide that level of care to more people in their communities."

- Cesar Herrera, Co-Founder and Chief Executive Officer, Yuvo Health

Partner health centers have already achieved shared savings by utilizing the technology and team that came together for Joe and also by gaining recognition for the work they were doing all along, with more accurate coding and risk adjustment. 

Now, health centers aren’t just surviving in today’s challenging environment — they’re positioned to thrive, grow, and deliver sustainable impact for the patients who rely on them most.

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