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.
For the most current information about the quality incentive measure, visit the CCO quality incentive program webpage. Also see these direct links to:
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.
Recent webinars
Engaging Health Care Providers in Social Needs Screening and Referral
Non-medical Transportation: Systems, Barriers and Opportunities
-
Slides /
Recording (4/22/25)
-
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.
Documenting and Sharing Social Needs Information in Pediatric Care Settings.
SDOH screening and referral technical assistance archive