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:

Social needs screening and referral measure specifications: 2024 / 2025
2024 SDOH social needs screening and referral self-attestation survey

Guidance documents

SDOH screening metric FAQ (updated January 2025)
Social needs screening training resources (December 2023)
Written agreements for social needs service provision (December 2023)
Playbook: This resource is an optional tool for CCOs to complete the work outlined in the technical specifications.
- Year 2: 2024 SDOH Screening and Referral Metric: Learning Collaborative Playbook (PDF)
- Year 1: 2023 SDOH Screening and Referral Metric: Learning Collaborative Playbook (PDF)
- Appendix A: Action planning tool (fillable Word doc)
- Appendix B: Project charter template (fillable Word doc)
- Appendix C: Sample survey questions for social needs screening partners (fillable Word doc)

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.

CCO memo: Transportation screening (7/31/24)

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 (more coming soon)

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)