Community health centers have long delivered whole-person, preventive care to the nation's most vulnerable populations. But for too long, the system has failed to recognize that work.

Value-based care (VBC) aims to reward these areas where health centers excel, but historically, the door to VBC has been closed to them for several reasons. Health centers are prohibited by regulations from taking on downside risk, often have a comparatively small patient population size to carry any clout when negotiating with payers alone, and they operate at razor-thin margins that can't accommodate upfront investments to technology and operational infrastructure.

Yuvo Health partners with health centers to change that. By assuming downside risk on their behalf and contracting with payers as an IPA larger than any individual member, Yuvo opens the door to VBC revenue health centers couldn't access on their own. And by pairing that access with a dedicated population health team and proprietary technology, Yuvo helps health centers succeed in those arrangements—getting them paid for the care they're already providing.

Here's how that partnership has unfolded at Joseph P. Addabbo Family Health Center, a community health center (CHC) that has served Southeast Queens and Brooklyn for nearly 40 years. The communities Addabbo serves are, as former CEO Dr. Miriam Y. Vega put it, "very rural in a way." Far Rockaway has only one CHC, and Red Hook has only one bus line. According to HRSA's Uniform Data System, 97.24% of Addabbo's approximately 30,000 annual patients are racial and/or ethnic minority populations, predominantly uninsured or on Medicaid.

The challenge

Like most health centers, Addabbo's care teams were working hard with limited tools and stifling blind spots. When a patient was hospitalized or visited an emergency department, that information could take weeks to reach the health center — if it arrived at all. Without timely data, chronic conditions were difficult to manage between visits, care transitions went unsupported, and the full complexity of the patient population wasn't captured in risk scores, leaving much-needed revenue on the table.

The solution

Yuvo Health partnered with Addabbo to enter value-based care arrangements the health center could not have accessed independently. Yuvo shoulders the downside risk, allowing Addabbo to strive for meaningful additional revenue without risking their overall sustainability. Yuvo then applied a combination of technology and people, designed to fully support an already overstretched team, to drive Addabbo’s success in their VBC contracts. 

Yuvo built data integrations pulling clinical and claims data from across the region: real-time ADT alerts, Addabbo’s EHR, and advanced analytics for patient risk stratification. 

A population health widget embedded directly in the EMR workflow now surfaces open care gaps and comprehensive patient histories at the point of care, so providers have the full picture before a patient even walks into the room. Ari Benjamin, MD, Chief Medical Officer at Addabbo, experienced this firsthand when the platform surfaced one of his patient's new diagnosis of acute kidney failure. The diagnosis was made during a recent hospitalization and he would not otherwise have known about it. 

“This 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.”

— Ari Benjamin, MD, Chief Medical Officer, Joseph P. Addabbo Family Health Center

Yuvo staff are physically present at Addabbo’s clinics several days per week for one-on-one provider education and pre-visit planning. The care management team conducts direct patient outreach, reconnecting patients recently discharged from hospitals and re-engaging those overdue for primary care visits. 

In one case, a Yuvo care navigator reached a woman who had completely lost track of her own health—she had been so focused on caregiving for a family member that her own care had fallen away entirely. That call got her back in the door for a breast cancer screening. The team also supports accurate risk adjustment coding so Addabbo is compensated for the true complexity of its patients.

“We never want to get lost in the data points. These aren’t just numbers; these are individual lives that we’re touching. Providing hands-on support to health centers allows them to continue providing the highest quality care.”

— Trenair Royal, Performance Manager, Yuvo Health

The results

In just their first year with Yuvo, Addabbo, improved their Breast Cancer Screening score from 57% to 61% of eligible patients. The partnership has led to a 33% increase in care gaps addressed during patient visits and a 20% overall increase in care gap closure. 

Addabbo also achieved shared savings in the first year of value-based contracting. Across the Yuvo Health network, partners generated $15.36 per member per month in total savings in year one (MY2022), growing to $24.29 per member per month in year two (MY2023).

Partnerships have also driven quality improvement across the Yuvo Health network, including Addabbo:

• 75% increase in quality gap closure (YoY, Q1 2024–Q1 2025)
• 65% improvement in quality performance across all health center partners (YoY, 2023-2024)
• 16% drop in overall ED use
• 29% reduction in inpatient visits
• 14% reduction in potentially preventable ED usage

Risk adjustment support has delivered an 11% increase in risk score from baseline in one MCO contract, translating to $30.68 more per member per month in risk-adjusted premium.

A model working across diverse communities

Addabbo’s results reflect a model working across a network of health centers serving some of the most diverse and underserved populations in the country, from LGBTQ+ communities and people experiencing homelessness, to immigrant and refugee populations, people with intellectual and developmental disabilities, and beyond. Yuvo works with each partner to co-build a plan tailored to their population, their strengths and their gaps.

Yuvo's team functions as a true extension of each health center's staff, taking on the outreach, auditing and training work that stretched teams simply can't get to on their own. Across the network, that commitment has meaningfully expanded what health center partners can do for their patients:

• 3,500+ patients reached across 12,000 targeted call or text outreach attempts

• 8,000+ chart audits completed

• 80+ provider trainings delivered to optimize workflows and tool use

“FQHCs always have a lot of challenges, but we feel like we can actually manage the chaos through some of these efforts to realign our incentives and create smarter, more patient-friendly workflows.”

— Mary Ellen Diver, CEO, Advantage Care Health Centers

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