A Radical New Approach to Diabetes Care – Vayu Health

Delivering person-centered high quality diabetes care to high-risk individuals with diabetes is no easy task in our current complicated health environment.  We are excited to share our interview with Dr. Avni Shah, Founder of Vayu Health, and her vision to provide equitable diabetes care delivery for our most vulnerable populations.  Dr. Shah and her team are proposing a radical new equity focused-approach to diabetes care.  To learn more, read our interview below.

Our vision is to transform the lives of under served Medicaid members living with multiple chronic conditions, behavioral health needs, and social determinants of health (SDOH) through a team-based approach to care that places people at the center of decisions about their own health. We are passionately driven to improve health, equity, and experiences for every person we work with, while also lowering costs,” said Dr. Avni Shah.

Dr. Shah says their care model is rooted in trusting relationships with patients, and also with the providers, community partners and health plans that they work with. To sustain vibrant, patient-centered programs they are designing a payment model that rewards their care team for doing the right thing at the right time for these vulnerable populations.

They believe that a major shift is needed in the way care is delivered for under resourced people living with chronic conditions, especially sub optimally managed diabetes, and are currently looking to build out their clinical team, including a Certified Diabetes Care and Education Specialist (CDCES) and a Licensed Clinical Social Worker (LCSW).

Interview with Dr. Avni Shah

1. What motivated you to leave a traditional work setting as a Peds Endo and take the risk to create a new health care model for Medicaid members living with diabetes?

Avni Shah, MD, Pediatric Endocrinologist: Previous diabetes director at Stanford Children’s and faculty leader for T1D national quality improvement collaboration. Currently volunteer faculty at UCSF. She had gestational diabetes requiring insulin, has pre-diabetes, and has a strong family history of Type 2 Diabetes.
  • It is really about who the traditional healthcare work setting failed that motivated me to leave: 1) patients and families living with chronic conditions, especially the underserved 2) my teammates and 3) my conscience (ie my moral injury).
  • We need something different and I believe it can be different. What we all need and strive for are: trusting relationships, joy in work and life, and direct translation of our work to better health and equity. We want to do what we know works, which is often not what can be supported and billed/paid in the traditional work setting.  

2. What do you consider the biggest shortcomings in our current approach to providing diabetes care?

    • Shortcomings that create barriers to doing what we know work are:
      1) the lack of alignment of what success looks like between a patient, the health system, and the health plan plus
      2) the lack of payment for your time (ie phone calls, home visits), needed innovations (ie virtual care, community integrations), and integrated team based resources (ie educators, coaches, behavioral specialists) to enable a personalized method for empowering patients to meet their goal(s).

3. Describe your future vision and model of diabetes care provision.

  • We believe that it is past time for a seismic change in chronic care management, especially for diabetes. Our primary-care based model is what is needed right now for people with diabetes and will include the following key components:

    • Whole-person care, integrating medical, behavioral, social, and self-management care
    • Team based approach including a local coach, CDCES, LCSW, and PCP
    • High-touch and flexible interactions, both in-person and virtual
    • Trauma-informed and culturally sensitive approach
    • Focus on building trust and engagement by identifying a person’s self-identified goals and helping achieve them
    • Utilize local community assets to address social determinants of health
    • Read more below

4. Do you have a favorite quote?

I have many quotes I love, but none that are a favorite. So here are a few:

  • You must be the change you want to see in the world. – Mahatma Gandhi
  • What you do makes a difference, and you have to decide what kind of difference you want to make. -Jane Goodall
  • I have found the paradox, that if you love until it hurts, there can be no more hurt, only more love. – Mother Teresa
  • Seek first to understand, then to be understood. – Stephen Covey

What is Vayu’s Goal? To Spark a Fundamental Change in Diabetes Care Delivery

Vayu Health was started by physicians who work extensively with adults and children with not only diabetes, but other chronic conditions, behavioral health issues and social risk factors. Vayu’s team recognized that despite best efforts of providers and patients, of new drugs and technologies, and of increased spending, population health outcomes have not improved significantly over the last 20 years for individuals living with chronic conditions such as diabetes, especially for those with low incomes. COVID-19 has only intensified the call for change as it has disproportionately impacted individuals already marginalized by our healthcare system failures.

To address this urgent crisis, fundamental change in the healthcare system is needed and Vayu Health is poised to create this change.

Identifying System Failures and Building Solutions

To successfully build their model, Vayu first identified the healthcare system failures, cataloging the barriers to people with diabetes receiving the right care. They identified four key barriers that needed to be addressed:

  • Right care at the right time: The healthcare system is not always known for flexibility or quick response time, and when serving large volumes of patients, can default to a one-size-fits-all approach. Individuals with chronic conditions however have a wide variety of needs depending on lifestyle, disease severity and the environment in which they live. The system must be able to match patients with the right care when and where they need it.
  • Treating the disease, not the person: A person with diabetes likely also has other clinical, behavioral and/or social needs, yet the delivery system frequently treats just the diabetes. To effectively support people with diabetes, programs must also address social issues, self-management needs, behavioral care, looking at the whole person instead of just the condition.
  • Lack of timely, accurate data: The healthcare system is composed of multiple parts and people, which commonly do not interact smoothly with each other. People with diabetes can see primary care providers, specialists, be admitted to hospitals and get lab work and prescriptions, and data from all of these entities are vital to tracking and managing their health and making informed decisions about their care.
  • Payment for some things, not always the right things: Treatment for people with diabetes works best when a team works together, each person contributing to the top of their license. However, payment for services does not always cover the cost of each staff member, requiring providers and their teams to make tough choices about how much they can invest in a team-based model.

Vayu Health’s Innovative Model

Vayu Health is taking on each of these systemic barriers, and addressing them in a cohesive, person-centered care model. As Medicaid members disproportionately experience care failures, Vayu is focusing on Medicaid managed care patients, living with diabetes and other chronic conditions.

They are collaborating with one of California’s largest Medicaid managed care health plans and a California community health center to develop and integrate Vayu Health’s unique systems approach, including a new value-based payment that will incentivize doing the right thing at the right time for patients. This collaboration is the first step in a systematic shift in the way community primary care providers and patients experience care and the way that Medicaid managed health plans cover the costs. 

In addition to the best practice chronic condition care model, a healthcare ecosystem will be developed which will incorporate the following system elements:

  • Alignment across providers, health plans and providers on care model and payment
  • Value-based payment to support the best practice care model (i.e. population based prospective)
  • Appropriate target population
  • Linkage of appropriate outcome and cost data
  • Continuous improvement driven by quality improvement methodology
  • Infrastructure/business financing needs
  • Technology required to enable effective team care

Equity-focused start-up is looking for innovators to launch a new diabetes care model:

Vayu Health is a California non-profit set to launch a completely different care model for people with diabetes living in under served communities, and is looking for like-minded people passionate about equity, person-centered care, and reducing barriers to accessing high-caliber diabetes care.

If you love working in an innovative team environment, are excited by participating in creative programming for patients, and are an independent thinker and self-starter, this just might be the perfect opportunity for you.  

The Vayu Team is looking for a CDCES and LCSW

The team is made up of people that are excited about building something new, and every team member regardless of role has a voice in creating the company.  Vayu believes passionately in reducing barriers to care for vulnerable populations, and has a strong focus on equity. The care team includes local community coaches, certified diabetes educators, licensed clinical social workers, and community clinic physicians.  With this multidisciplinary team, care delivery will be a combination of coordinated, proactive in-person and virtual care, delivered when and where the patient needs it.

Vayu has the commitment of the community clinic and Medicaid healthcare plan, as well as national experts in diabetes care, Medicaid managed care healthcare payment reform, and chronic care system design and optimization.

Link to CDCES Job Description

Link to LCSW Job Description


  • Avni Shah, MD, Pediatric Endocrinologist: Previous diabetes director at Stanford Children’s and faculty leader for T1D national quality improvement collaboration. Currently volunteer faculty at UCSF. She had gestational diabetes requiring insulin, has pre-diabetes, and has a strong family history of Type 2 Diabetes.
  • Margie Powers, MSW, MPH: Design and implement population health initiatives for provider groups, health plans and self-insured employers across the country, with focus on serving Medicaid populations at Federally Qualified Health Centers in California. Previously Director of Medically Complex Patients Program at Purchaser’s Business Group on Health in San Francisco.
  • Alan Glaseroff, MD, Family Practitioner (pro bono): Designed and led Stanford Coordinated Care (SCC) and Humboldt Diabetes Project which both showed significant improvement in outcomes, patient experience, patient activation, utilization, and costs. He has lived with Type 1 Diabetes since 1983.
  • John Bertko, F.S.A., M.A.A.A. (pro bono): Actuarial consultant serving as the Chief Actuary with Covered California (California’s Insurance Marketplace). Past Director of Special Initiatives and Pricing in the Center for Consumer Information and Insurance Oversight at the Centers for Medicare and Medicaid Services (CMS) and Chief Actuary of Humana Inc.

This is an incredible opportunity to join a dynamic mission-driven company with visionary leadership and a bold and inclusive culture.  Interested people should directly contact Margie (margie@hellovayu.org or 415-225-4787).

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.