Yuvo helps FQHCs reduce costly hospital and emergency department (ED) use with patient engagement and outreach support

Federally Qualified Health Centers (FQHCs) are the backbone of community-based care, meeting patients where they are and providing trusted, preventative services. But even with their deep commitment and reach, many patients still turn to emergency departments rather than primary care, resulting in lower quality of care for the patient and higher costs for the healthcare system. 

Connecting with these patients is critical, especially with upcoming Medicaid cuts which could result in the loss of coverage for millions. But with the right support, resources, and outreach efforts, FQHCs can re-engage these patients before crises occur, getting them better quality care and helping to prevent avoidable emergency visits. 

We don’t just know this; we’ve proven it. Since they partnered with Yuvo Health – and started utilizing Yuvo’s support systems – our FQHC partners overall have seen meaningful reductions in unnecessary utilization, including a 16% drop in overall ED use, a 14% decrease in potentially preventable ED usage, and a 29% reduction in inpatient visits according to 2023 - 2024 data from our Fidelis VBC arrangement.  

We provide partners with data-driven insights to identify high utilizers, then work alongside care teams to engage these patients with outreach, education, and coordinated scheduling.

This has helped FQHCs to lead a vital shift in the patient-provider relationship—one they have long prioritized—away from episodic, emergency-based encounters toward consistent, whole-person care. This doesn’t just reduce costs, but allows for greater care access and contributes to more optimal patient outcomes.

Lower costs, improve care quality

Studies show that the top 5% of healthcare users account for 50% of all healthcare costs. These high utilizers are often dealing with socioeconomic concerns like housing instability and food insecurity, may not be connected with social services, and may be dealing with various health and mental health conditions, and would benefit greatly from preventative care.

One of the best ways to reduce ED utilization and improve the quality care provided to these patients is to connect them to primary care services. One study shows that undocumented immigrants who received assistance in scheduling visits with primary care physicians experienced a 21% reduction in ED use – and those with high-risk medical profiles who received the same help experienced a 42% reduction in ED use.

Primary care visits don’t just prevent unnecessary admissions, but they help lower costs, increase access to care, and most importantly, improve community health outcomes. Unfortunately, many FQHCs don’t have the bandwidth or resources required to assess patient populations, identify high utilizers, and conduct outreach – but Yuvo does. 

“We really try to understand the health centers and meet them where they are. Whether that’s based on data, assessment findings, or the FQHC identifying what they need at that moment. The goal isn’t just to build relationships, but to understand the health center holistically so we can build doable strategies that make a significant impact.” 

-Cassie Parks, RN, Director of Care Management, Yuvo Health

Here is how we are creating that significant impact together:

Identify and analyze utilization data

To help FQHCs operate more efficiently and deliver better care, Yuvo provides its partners with a myriad of strategies, support systems, and tools to better identify and reach patients. Conducting comprehensive data assessments, Yuvo is able to stratify patients by risk level and identify high utilizers, as well as those who’ve been recently discharged.

Knowing there is a cohort of patients who have shown high utilization of ED visits (3-4 across the year) and who have not visited a health center or primary care provider in 6 months to a year, for example, FQHCs can start to re-engage them. 

But not all FQHCs have the resources to do so, which is why Cassie and the Care Management team at Yuvo provide scripting for patient phone calls, guided conversations, and coaching to FQHCs in addition to the data for more effective post-discharge planning.  

By providing utilization and engagement data to the internal care management team at Callen-Lorde, for example, Yuvo has helped the FQHC surface impactful members so they can take ownership of the outreach, engagement, and scheduling. 

Provide guidance around patient engagement 

When our FQHC partner Joseph P. Addabbo Family Health Center identified high utilizers who had never been to the primary care provider or were unable to access care due to insurance or other barriers, Yuvo helped navigate these conversations by providing scripts for discussing payer benefits and addressing the issues that were preventing patients from scheduling appointments. 

"Outreach has been very helpful and made an impact. It's led to patients attending their appointments and reconnecting with those who have not been seen or spoken to in some time." 

– Louis Raymond, Case Manager at Joseph P. Addabbo Family Health Center

Conduct direct patient outreach

“When evident and needed, we step in to provide support in areas that are hugely impactful, whether it’s utilization, quality, or patient engagement, which helps offload this work from the health centers,” says Cassie. 

While many FQHCs are able to utilize the information provided and do the work internally, others don’t have the staff or resources needed to support the workflows. This is why Yuvo now engages patients on behalf of FQHC partners. 

Related: Driving quality improvement in breast cancer screening: Yuvo Health's approach with FQHCs

Working with Addabbo, for example, Yuvo conducts direct outreach to recently discharged patients in the hopes of preventing them from readmission and getting them scheduled for a primary care appointment within a few days of discharge. Yuvo also supports Callen-Lorde with their outreach efforts, including reaching unengaged patients to schedule them for Annual Wellness Exams – and have made this service available to any FQHC partner who needs it. 

At Yuvo, we’re constantly reevaluating the status of our health centers so we can help FQHCs sustain and scale. And we know, the more patients that engage with primary care, the more we can prevent avoidable emergency visits, improve outcomes, and advance health equity. By meeting patients where they are and stepping in when extra capacity is needed, Yuvo ensures FQHCs can continue doing what they do best: delivering high-quality, community-rooted care that keeps people well and out of crisis.

Related: FQHCs receive true partnership and make lasting impact with Yuvo Health

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