Skip to main content

Oregon State Flag An official website of the State of Oregon » Homepage

Social determinants of health (SDOH) incentive metric

Social needs screening and referral measure 

Social determinants of health (SDOH), like access to stable housing, nutritious food and transportation, affect a person’s health outcomes and quality of life. In May 2022, the Metrics and Scoring Committee added the SDOH: Social Needs Screening and Referral measure to the 2023 set of coordinated care organization (CCO) incentive measures. CCOs began measure implementation in January 2023. The goal is that CCO members have their social needs acknowledged and addressed.

Specifications and guidance

Social needs screening tools

See the list of OHA-approved screening tools. OHA strongly encourages CCOs and organizations conducting SDOH screenings to use tools from the OHA-approved SDOH screening tools list. CCOs may request that other tools be reviewed for approval.

2023-24 technical assistance

The Transformation Center is partnering with OHSU’s Oregon Rural Practice-based Research Network (ORPRN) to support CCOs and their partners to implement the social needs screening measure. See technical assistance flyer for full details. 

OHA can provide sign language and spoken language interpreters, written materials in other languages, braille, large print, audio and other formats. If you need help or have questions, please contact Claire Londagin ( at least 48 hours before the meeting.

Café Connect Series 

Audience: CCOs, CBOs and providers 
Opportunities to hear from experts and allow for CCOs, CBOs and providers to strengthen partnerships and support successful metric implementation. All sessions are 1-2 p.m.
  • September 18, 2023 - Orientation and overview of metric requirements: Slides / Recording
  • October 24, 2023 - Health and social care integration: sustainable partnerships: Slides / Recording
  • January 23, 2024 - Payment arrangements for social needs screening and referral: Slides / Recording
  • March 18, 2024 - Data coordination between social services and CCOs: Slides / Recording
  • May 23, 2024 - Optimizing data sharing systems: Register here 

CCO learning collaborative 

Audience: CCO measure leads
CCOs will share strategies to address high-priority needs and metric must-pass elements. All sessions are 3-4 p.m.
  • September 28, 2023 - SDOH metric grounding: Slides / Recording
  • November 13, 2023 - Protocols and practices to prevent over-screening: Slides / Recording
  • February 29, 2024 - Social needs screening training and resources: Slides / Recording
  • April 25, 2024 - Addressing referral resources and gaps through use of REALD: Register here 
  • June 18: Cancelled

CCO coding and value-set round table discussion

Audience: CCO measure leads
CCOs will share and discuss their approaches to codes and value sets for tracking screening and referral data for the metric.

CCO office hours 

Audience: CCO measure leads
Drop-in office hours are an opportunity to discuss pressing questions with TA providers and other CCO measure leads. TA and information on a specific topic area will also be featured.
  • October 27 (EOCCO Frontier Veggie Rx): Recording
  • December 8 (using aggregated REALD data): Recording
  • February 16 (data sharing at point of care): Slides / Recording
  • April 12 (aligning SDOH metric with the 1115 waiver and other upstream initiatives): Slides / Recording
  • June 14: Cancelled

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 (

2022-23 technical assistance

Recorded webinars

Audience: All CCO staff directly or indirectly involved in implementing the social needs screening and referral metric.
  • Community information exchange (CIE) and other platforms (5/30/23) - Recording / Slides
    • Follow-up session: CIE and other platforms (6/23/23) - Recording / Slides
  • Data collection and sharing (5/2/23) - Recording / Slides
  • SDOH screening practices (1/30/23) - Recording / Slides
  • Referral practices and resources (3/28/23) - Recording / Slides
  • SDOH metric grounding webinar for CCOs and providers (11/8/22) - Recording / Slides
  • SDOH metric grounding webinar for CCOs and community-based organizations (11/11/22) - Recording / Slides 


This SDOH Metric Learning Collaborative Playbook (with fillable templates) is designed to provide optional tools your CCO may use to complement each learning collaborative and the technical specifications. 


Contact: Rachel Burdon (