Social determinants of health (SDOH), like access to stable housing, nutritious food and transportation, affect a person’s health outcomes and quality of life. Since 2023, the SDOH Social Needs Screening and Referral measure has been one of the coordinated care organization (CCO) incentive measures. The goal is for CCO members to have their social needs acknowledged and addressed.
Guidance documents
Social needs screening tools
See the list of
OHA-approved screening tools. OHA strongly encourages CCOs and organizations conducting social needs screenings to use tools from the OHA-approved SDOH screening tools list. CCOs may request that other tools be reviewed for approval.
Technical assistance
OHA offers support to CCOs and their partners working on the SDOH social needs screening incentive metric. See below for current and past technical assistance sessions.
Current technical assistance
Learning collaborative: Engaging Health Care Providers in Social Needs Screening and Referral
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Slides /
Recording (3/18/25)
- Audience: CCO staff
- This learning collaborative offers participants actionable strategies to effectively engage health care providers in social needs screening and referral activities.
Webinar: Non-medical Transportation: Systems, Barriers and Opportunities
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Slides /
Recording (4/22/25)
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Non-medical transportation resource list
- Audience: CCO staff, community-based organizations
- The Oregon Accountable Health Communities study found that 17.2% of all patients screened had insufficient transportation. This webinar will describe the transportation systems in Oregon and the opportunities to invest in and leverage transportation infrastructure to increase equitable access to social resources with guest speakers from the Oregon Department of Transportation.
Learning collaborative: Navigating the SDOH Screening and Referral Playbook
- Audience: CCO staff
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Part 1: Slides / Recording (5/20/25)
- This learning collaborative will orient CCO staff to the 2025 SDOH Screening and Referral Metric Playbook as an optional planning tool for implementing the social needs screening and referral metric.
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Part 2: Slides / Recording (6/4/25)
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This learning collaborative will build on the previous session, with focus on applying change management strategies for successful implementation.
Webinar: Documenting and Sharing Social Needs Information in Pediatric Care Settings.
Individualized CCO technical assistance
One-on-one technical assistance is available to all CCO staff responsible for metric implementation throughout the year. Support will be tailored to the needs of individual CCOs. To request technical assistance, email Claire Londagin (
londagin@ohsu.edu).
Past technical assistance