Caring for patients with diabetes can be complex—and you don’t have to do it alone

Vayu Health partners with providers to help patients make small, sustainable changes that lead to lasting improvements in health and wellbeing.

Our program offers free, Enhanced Care Management (ECM) PLUS more through our CHW, registered dietitian & diabetes educator, and behavioral health care team.

We specialize in supporting members with uncontrolled type 1 or type 2 diabetes, our population of focus often differs from those typically served by standard ECM providers. This means our work often does not interfere with other ECM providers in the community."

We focus on understanding what matters most to each person and reinforcing your care plan through education, self-management coaching, and well-being & social support.

Refer your patients today to help them access additional wraparound support for diabetes management, nutrition, mental health, and social needs.

Check out the FAQ section for more information!

Refer Today!
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HIPAA Compliance Notice

All patient information submitted through this referral form will be maintained in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable privacy regulations. The information provided will be transmitted and stored securely, and used only for purposes related to patient care coordination and follow-up. We are committed to protecting the confidentiality and integrity of all Protected Health Information (PHI) received through this form.

 FAQs

 

    • Saves provider time by addressing complex needs between visits

    • Integrated diabetes, social, and behavioral support

    • Clear feedback loop with regular updates

    • Local, in-person support (not all virtual)

    • No cost to practice or patients

    • Easy referral via email, phone, or fax

    • Vayu contacts patient to explain program and enroll

    • CHW accompanies patient to PCP visits

    • Team sends periodic updates via secure channels

    • Graduation when patient achieves sustained improvements

    • Complement, not replace: We extend your care team by taking on high-touch work that is resource-intensive and often unreimbursed.

    • Support: Trained multidisciplinary team (CHW, BH, RD-CDCES) addressing diabetes, engagement, well-being, behavior change, and SDOH barriers at no cost to your clinic and no billing/claims changes for you.

    • Impact: Frees up provider/staff time, improves attendance at appointments, and returns patients more stable and engaged.

    • Results: Improved quality metrics (ex: HEDIS >9% diabetes control), empowerment/self-management (ex: PAM score), PCP/Staff/member satisfaction (from qualitative interviews by an outside group)

    • Vayu Health serves Partnership HealthPlan of California and Health Net members in Humboldt, Shasta, and Stanislaus counties,  aged 18 or older with Type 1 or Type 2 diabetes who meet at least one of the following criteria:

      1. Last A1c greater than 9% within the past 12 months

      2. Three or more preventable ER visits, one preventable hospitalization, or an avoidable short-term skilled nursing facility stay with an A1c greater than 8% in the past 6 months

      3. Pregnant with poorly controlled pre-existing diabetes (A1c greater than 8%)

    • If you’re unsure whether a member qualifies, feel free to submit the referral—Vayu Health will screen for eligibility.

  • Members currently receiving palliative care are not eligible for the program.

    • Yes. Vayu Health offers Enhanced Care Management (ECM) services PLUS more for a unique population of focus for people with uncontrolled diabetes.

    • Our integrated team—including local in-person Community Health Workers (CHWs), virtual Licensed Clinical Social Workers (LCSWs/LMFTs), and Registered Dietitians (RDs-CDCES)—helps address:

      1. Transportation, pharmacy, and food access

      2. Emotional and mental health needs

      3. Diabetes education and self-management coaching

      4. Insulin titration between visits

      5. Continuous glucose monitoring (CGM) setup and support

      6. Coordination and reinforcement of the primary care plan

    • Vayu Health complements, not replaces, local clinical providers.

    • Yes—if the member meets the referral criteria above

    • If a member is already enrolled in another ECM program, participation in Vayu Health is still the member’s choice based on our unique population of focus and extra care services.

    • Vayu Health is also embedded within the Open Door FQHC referral system for direct referral.

    • Whenever possible, introductions should come from someone the member already trusts—such as a PCP, MA, or care coordinator. We call this a warm referral.

      • Vayu provides flyers and outreach materials to help with introductions.

    • In addition, Vayu periodically receives lists of potentially eligible members and may conduct outreach directly, even if not referred by a provider.

  • Any staff or provider can initiate a referral. Vayu Health will confirm eligibility and notify the referring individual of the outcome.

  • Vayu Health will contact the potential member, explain the program, and invite them to enroll.