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 measure specifications, see the CCO quality incentive program webpage.
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 OHA review other tools for approval.
Technical assistance
OHA offered support to CCOs and their partners working on the SDOH social needs screening incentive metric.
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 found that 17.2% of all patients screened had insufficient transportation. This webinar describes the transportation systems in Oregon and the opportunities to invest in and leverage transportation infrastructure to increase equitable access to social resources. Guest speakers are from the Oregon Department of Transportation.
Documenting and Sharing Social Needs Information in Pediatric Care Settings.
Data collection and sharing
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Electronic Health Records, Chart Review and Claims-related Data for Component 2 Reporting:
Slides (1/21/25)
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CCO coding and value-set round table discussion
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Data sharing at point of care:
Slides (2/16/24)
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Data collection and sharing:
Slides (5/2/23)