2024 Annual Report: An ecosystem of support for community health centers

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A message from Yuvo Health co-founder and CEO Cesar Herrera

This year, collaboration has emerged as a pivotal theme in our mission to enhance community health. The NYS 1115 Waiver Amendment has brought this focus into sharp relief, with both new opportunities and guidelines for how the ecosystem must work together. We’re motivated by this because collaboration isn’t just a buzzword for us; it’s integral to everything we do, as you’ll see in this annual report. 

Working hand-in-hand with community health centers (CHCs), we’ve witnessed firsthand the transformative care they provide to historically disenfranchised communities. With the right support, these centers are not just serving their communities—they are creating generational impact. 

That’s why we’ve prioritized increasing access to data analytics, population health information, and coding and documentation tools. Our partners are now performing better than ever, unlocking new revenue streams and elevating the quality of care they deliver. We’re proud to have supported our CHC partners in making substantial improvements in quality metrics, addressing social barriers to care, and achieving much-deserved shared savings in just the first year of our value-based contracting program.

Value-based care: the future of healthcare

We recognize that value-based care represents the future of healthcare, and we are dedicated to this mission. By serving CHCs, we are ultimately serving our communities—something that has drawn many to the Yuvo team, including our newest independent Board member, the committed public health leader Dr. Dave A. Chokshi. Our team now comprises over 50 dedicated individuals spanning multiple time zones and whose backgrounds mirror the diversity of the communities CHCs serve.

Growing a remote-first company that prioritizes culture and connection has proven invaluable. We’ve strengthened our partnership with The Darkest Horse, opened new offices, hosted energizing company off-sites in Texas and India, and invested in countless in-person working sessions.

Empowering our mission 

Our mission is tangible and achievable. And I grow even more determined as we pave the way toward realizing it. We have assembled a talented team and are witnessing a wave of new national policies, technological innovations, and partnerships among government agencies, health plans, providers, and community organizations. By building upon these partnerships and expanding our network of collaborators, we aim to provide even greater support to our CHC partners. Together, we can ensure they continue delivering the life-changing services that so many, including myself, have benefited from. 

- Cesar Herrera, Co-founder and CEO of Yuvo Health 

Yuvo Health exists to support community health centers

Yuvo Health partners with community health centers (CHCs) so they can focus on what they do best: provide compassionate care to their communities. 

Our mission:

Ensure every community health center can provide compassionate care to their entire community.

Community health center partners  

Yuvo Health proudly partners with community health centers serving diverse populations and communities across the country.

Opening the door to value-based care for community health centers

A message from David A. Chokshi, MD, Independent Board Member, Yuvo Health

Dr. Chokshi is a physician at Bellevue Hospital, Sternberg Family Professor of Leadership at the City College of New York, and the former New York City Health Commissioner. 

I was honored to join Yuvo Health as an independent board member this past year. Yuvo’s mission—to ensure every community health center can provide compassionate care to their entire community—deeply resonates with me, as a physician and public health leader.

I first learned how to practice primary care at a community health center in Jamaica Plain, Massachusetts. And throughout my career, I have seen firsthand the impact community health centers (CHCs) have by delivering high-quality, high-value care to marginalized patients and communities across the nation.

While CHCs are rooted in high-need communities, the impact of their care ripples outward to everyone. CHCs are responsible for generating nearly $85 billion in broad economic benefits annually, including more than half a million high-quality jobs, and are instrumental in controlling spiraling national healthcare costs.

Three-quarters of CHCs reported their clinical quality benchmarks would qualify them to receive financial incentives in a value-based care model in 2017. The problem is, only 39% participated in accountable care at that time.

While health centers are naturally positioned for success in value-based care, an arena where other providers have been able to unlock additional resources, too often the door has been closed to CHCs.

That’s where Yuvo comes in. We’re creating value-based care options designed specifically for health centers. With early success in earning shared savings, Yuvo is already proving that CHCs can garner additional resources for their vital mission — and be crucial partners in a value-based care network. As we build upon this, Yuvo aims to further demonstrate the remarkable value health centers bring to patients, communities, payers, and the healthcare system as a whole.

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The FQHC experience with Yuvo Health 

When an FQHC joins Yuvo Health, they gain a partner every step of the way—to immediately reduce the burden, provide consistent additional revenue, and drive success toward shared savings.

1. Contracts that deliver more revenue for FQHCs

FQHCs gain access to new, better contracts with the autonomy to choose.

100% of Yuvo’s FQHC partners are participating in new value-based contracts with greater earning potential and with payers they have not previously had access for value-based contracting.

‍2. Discovery and co-development of a customized plan

Each FQHC is unique. We meet you where you are.

At our initial visit to onboard Aizer Health, the Yuvo team noticed an asset the health centers already had in place: digital monitors on the outside of all examination rooms. We worked with the Aizer team to repurpose the monitors beyond rooming to improve pre-visit planning and help providers better address care gaps during patient visits. Not only will this help one FQHC, but the learnings are shared with all partners as part of our learning collaborative.‍

3. Curated patient profiles, conveniently in the EHR

Seamless tech integrations equip providers at the point of care.

Joseph P. Addabbo Family Health Center (JPA) providers and team members can now view claims data, patient health history, admissions, discharges and transfer (ADT) data and more from multiple sources directly in their EHR, at the point of care with technology provided by Yuvo. Providers and care teams gain more insight into open care gaps and suggested opportunities and also save time because of the automated documentation. Now, providers can maximize their time with the patient and as a result, the JPA team can accomplish more in less time.

“Adopting the VIM Population Health Platform has been a transformative step for our organization. The platform’s robust data capabilities have empowered our providers to make more informed clinical decisions, ultimately enhancing the quality of care we deliver to our patients. We are excited about the potential of this tool to continue improving health outcomes for our community.”

- Ari Benjamin, MD and Chief Medical Officer at Joseph P. Addabbo Family Health Center

4. Hands-on support and expert guidance on VBC performance

Guidance, coaching, 1:1 education sessions and hands-on support to help FQHCs meet performance goals. 

After uncovering frequent scheduling gaps at one of our FQHC partners, the Yuvo Population Health team reviewed charts and discovered a challenging trend: patients were canceling appointments without rescheduling. The health center lacked the resources to reach out to each patient, so Teresa, Yuvo Health Clinical Quality Outreach Manager, stepped in to make the calls. Next, we introduced a multi-language text messaging capability that enables consistent, simple patient outreach moving forward. The initiative led to increased well-visits—boosting revenue and improving quality for the FQHC.

5. Augmented support for risk, quality and care management

Assisting FQHCs with care management, patient outreach, engaging partners and however else they need us.

While analyzing trends across our FQHC partners, the Yuvo Health Care Management team identified a need and established a partnership with God’s Love We Deliver, a community-based organization that provides free, medically-tailored meals to people with life-altering illnesses. The Yuvo team handles the entire coordination process, from contacting patients to referring them to God’s Love We Deliver, who then schedules and delivers appropriate meals on an ongoing basis.

6. Collaboration with other FQHCs

FQHCs who have historically been left out of ACO and IPA discussions get an equal seat at the table with Yuvo.

“As a member of the Yuvo Health IPA, we now have the ability to partner and network with other, like-minded FQHCs. We have already begun independently sharing best practices with our fellow IPA partners.”

- Anthony Fortenberry, RN, Chief Population Health Officer, Callen-Lorde

‍7. Revenue and shared savings opportunities

FQHCs receive monthly, upfront payments while Yuvo manages the VBC contracts to drive more revenue through shared savings.

At each of these steps, we aim to create an immediate impact for FQHCs while paving the way for long-term success in value-based contracting. That proved to be the reality for our partners who achieved shared savings in their first year of our value-based contracting program.

Related: FQHC value-based care incentive program

Within one year, value-based  care models prove beneficial  for FQHCs 

A message from Carmelo Cruz Reyes, MPH, Co-Founder and Market President

As someone who has been in the value-based care (VBC) and social care spaces on both the health plan and provider side for close to twenty years, I know that value-based care holds enormous promise for patients and FQHCs—who already deliver exceptional care at low costs. 

We don’t just know this to be true; we’ve now proven it possible. 

Partnering with Fidelis Care and various New York-based FQHCs, we have successfully achieved shared savings. Within the first year alone, participating FQHCs generated $15.35 per-member-per-month (PMPM) total savings to the network and produced gains in high-value quality metrics, including a 20% improvement in gap-to-goal for potentially preventable admissions and readmissions.  

This is a remarkable achievement that often eludes larger, more established organizations. So how did we do it?  

It all started with trust, dedication and a shared commitment from each participating stakeholder. Then we worked closely with our FQHC partners and supported them every step of the way, as you read in this report. 

What’s most exciting is that we not only achieved shared savings, but we helped demonstrate the importance of bringing FQHCs to the table and recognizing that they are truly outstanding leaders on the path to equitable, accessible, value-driven care. 

Related: Transitioning your FQHC from fee-for-service to VBC

How Yuvo Health drives success in value-based care

We...

• Collaborate with our payor partners to create more equitable value-based payment contracts designed for FQHCs. 
• Ensure financial targets are realistic, achievable and aligned with FQHCs’ actual performance and add gap-to-goal clauses to capture improvement FQHCs can drive—making sure they get credit for the work they’re doing.  
• Negotiated for the first-ever incentive payments from a payor to FQHCs, creating a new and reliable stream of revenue for them. 
• Push to ensure all FQHCs, regardless of their size, have a seat at the table for value-based care. That’s why Yuvo does not close its doors to any FQHC. 
• Helped several of our FQHC partners become in-network for payors they were previously out-of-network for.
• Enable FQHCs to incrementally progress through various levels of VBP contracts, from level one to full-risk, with access to greater revenue opportunities while Yuvo shoulders the financial risk.

FQHCs achieve ongoing quality improvement 

65% improvement in quality performance

Yuvo Health improved in quality performance in every metric for which we had full-year data across both 2022 and 2023, including:

Many of these quality improvements reflect work that FQHCs were already doing, but were not getting credit. With Yuvo conducting supplemental chart reviews and submitting documentation, FQHCs are now meeting more quality metric targets.

* Figures represent a year-over-year change across all FQHC partners.

Technology enables a leap forward for FQHCs

A message from Sujata Bajaj, Chief Technology Officer

At Yuvo Health, we’re thrilled to be eliminating barriers that have prevented FQHCs from seeing the complete picture of their patients’ health and blocking them from providing high quality care to more people.  

Health technology is often rife with information gaps, months-long lag times for critical data and extra work for providers. So it has been our focus to develop and deploy solutions that offer a comprehensive view of a patient’s health history in a way that is easily accessed, right at the point of care.  

We have made huge strides this year in strengthening the suite of tools that enable providers to better identify, engage and care for their patients. Some of these new capabilities include:  

Complete view of a patient’s health history at the point of care 

Providers can now access patient data from multiple sources without the traditional 90-day wait for claims data, right in their EHR. This is already live at some of our FQHC partners, with more to come in the following months.  

Multi-language text messaging campaigns to engage patients 

FQHCs are now able to easily alert their patients when they are due for a preventative visit or to follow up after a hospitalization.  

A data warehouse to create a unified patient profile 

Our new, comprehensive data warehouse empowers FQHCs with the clarity and confidence to assign patient data from various sources to the right person. 

In the coming months, we’re excited to enable FQHCs with greater care management capabilities by providing real-time access to admission, discharge and transfer data and to make the data even easier to understand with enhanced visualization. We’re also looking to extend our technology to help FQHCs in NY get more credit for their work within the Social Care Network (SCN) and lower the barriers for integration.  

Together, these tools create an ecosystem for providers, who gain the ability to identify and engage patients who need to be seen, a full picture of the patient’s health history and help managing treatments and follow-up care.  

The right tools in the right hands 

We build seamless tech integrations to collect, analyze and operationalize data, giving FQHCs the following:

Partnering with leading tech providers

A curated suite of technology products and partners to bring new capabilities to our FQHCs.

An ecosystem of support for FQHCs

The NYS 1115 Medicaid Waiver Amendment, also known as the New York Health Equity Reform (NYHER), runs from 2024 through 2027 and provides $6 billion in federal funding to address health equity and social determinants of health in New York. Close to half (47%) of the budget is allocated towards the provision of health-related social need services, which represents a huge opportunity to reshape social care delivery in New York.  

Social Care Networks (SCNs) are essential in this effort, and responsible for screening Medicaid patients for HRSNs and navigating them to appropriate social care services in collaboration with community-based organizations (CBOs). FQHCs will be core drivers for success in this endeavor and their participation in the SCN gives them a pathway to be reimbursed for the screening, navigation, and enhanced services they provide. 

Yuvo Health is proud to be a partner for social care network leaders like Public Health Solutions (PHS). We look forward to continuing our collaboration with PHS, Community Health Care Association of New York State (CHCANYS) and other SCNs by leveraging our technology, network and best practices to help FQHCs navigate and succeed in the new dynamic.

A proud partner

Yuvo Health is a member of National Association of Community Health Centers (NACHC), Community Health Care Association of New York State (CHCANYS) and Advocates for Community Health (ACH).

We continue to forge partnerships with like-minded organizations like Coordinated Behavioral Care (CBC), Public Health Solutions (PHS), primary care associations (PCAs) and others serving community health centers.

FQHC partners’ well-deserved accolades and achievements

In conclusion

We’re thrilled to demonstrate how FQHCs can excel when they have access to the right resources. The achievement of shared savings in just the first year of our value-based contracting program is a testament to the untapped potential of FQHCs and further strengthens our resolve to extend our support to more health centers and their communities.  

“One of the beauties of Yuvo, at least for Metro, was the opportunity to begin our participation in the VBP world. When Metro first engaged with Yuvo, we were not VBP ‘ready.’ We were not given any opportunities by payors. We were too small and insignificant to be involved in the conversation and the programs. Yuvo provided both the opportunity and the support for us to begin engagement with VBP.” 

- Dr. Rita Bilello, Chief Executive Officer, Metro Community Health Centers 

We’re building on early success and look forward to continuing to open the door to value-based care and sustainable futures for all FQHCs. As the wider healthcare system embraces and prioritizes collaboration, health centers are poised to emerge as the lynchpin to building robust care networks and healthier communities. At Yuvo Health, we’re excited to help turn that potential into reality.  

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