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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 is designed to offer participants actionable strategies to engage health care providers in social needs screening and referral activities effectively. 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. By exploring real-world examples, participants will gain valuable insights to support providers in embedding social needs screening into their care practices.
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.
Webinar: Screening Pediatric Populations for Social Needs
  • Date: TBD
  • Audience: CCO staff, health care providers and clinical staff
  • There are unique considerations when building a social needs screening and referral system for the pediatric population. Questions have surfaced from CCOs and providers throughout Oregon regarding appropriate screening approaches for adolescent patients, best practices for social needs screening workflows in pediatric clinical settings, and reducing over-screening of caregivers through good documentation practices. This webinar will help the audience understand the unique needs of screening pediatric populations for social needs, and introduce some practice-based approaches to address these challenges.
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)