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Social determinants of health (SDOH) social needs screening and referral: Quality incentive measure technical assistance

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 curent information about the quality incentive measure, visit the CCO quality incentive program webpage. Also see these direct links to:

2026 draft specs

On March 19, OHA released the 2026 draft specifications for the SDOH measure. Public comment is due April 16 at Metrics.Questions@odhsoha.oregon.gov. For more information, see the March CCO TAG slides (20-31).  

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
  • Slides / Recording (3/18/2025)
  • Audience: CCO staff
  • This learning collaborative offers participants actionable strategies to effectively engage health care providers in social needs screening and referral activities. Attendees will learn from providers who have successfully integrated these processes into their workflows and will have the opportunity to discuss shared challenges and practical solutions. The session will highlight tools, resources and promising approaches to address barriers, streamline workflows and build provider buy-in. 
Webinar: Non-medical Transportation: Systems, Barriers and Opportunities
  • April 22, 2025, 1-2 p.m.
  • Audience: CCO staff, community-based organizations
  • Register here
  • Transportation is a barrier to accessing social resources for urban and rural Medicaid members alike. 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
  • Part 1: May 20, 1-2 p.m.
    • Register here
    • 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. Through guided discussions participants will actively engage with the playbook, working through key sections and discussing how to apply them to their own implementation efforts. Participants will have the opportunity to collaborate with peers to share insights, challenges, and solutions for effective metric implementation. 
  • Part 2: June 4, 2-3 p.m.
    • Register here
    • This learning collaborative will build on the previous session by continuing work in the SDOH Screening and Referral Metric Playbook, with focus on applying change management strategies for successful implementation. Participants will deepen their understanding of how they could use the playbook to overcome challenges and create solutions that advance social needs screening and referral practices. Through interactive discussions and activities, CCOs will explore strategies to manage organizational change and engage partners in screening and referral.   
Webinar: Aligning Systems for Social Needs Screening and Referral in Oregon
  • June 17, 1-2 p.m.
  • Audience: CCO staff, clinical partners, community-based organizations (CBOs)
  • Register here
  • As momentum picks up around screening for social needs in both clinical and community settings, clinical and community providers are asked to meet multiple requirements from various governing bodies and payment plans around screening their patients for social needs and referring them to resources. This webinar focuses on the various social needs screening and referral initiatives impacting CBOs and clinics in Oregon. ORPRN will present a systems map and highlight intersections that CCOs can use to streamline the experience for their patients, clinics and CBO partners. 
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

See past webinars and learning collaborative presentations for this metric. Topics include screening and referral practices, data collection and sharing, and more.

Contact: Rachel Burdon (Rachel.E.Burdon@oha.oregon.gov)