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 for CCO members to 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.
2024-25 technical assistance
Join the Oregon Health Authority (OHA) and Oregon Rural Practice-Based Research Network (ORPRN) for interactive sessions around Component 2 of the SDOH Metric. Explore innovative approaches and exchange insights on metric data and reporting
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 (
londagin@ohsu.edu) at least 48 hours before the meeting.
CCO community of practice: Overview and deep dive on community information exchange (CIE) data
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Slides
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Recording (9/11/24)
- Develop a shared understanding of various data sources available for SDOH screening and referral to inform a comprehensive data collection strategy.
- Explore how CIE data can enhance existing SDOH data collection efforts within CCOs and share best practices for integrating CIE with other SDOH data sources.
Webinar: Building community-based organization (CBO) capacity and engagement with CIE
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Slides
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Recording (10/23/24)
- Gain insights from CBOs on their experiences using CIE.
- Learn about CBO strategies to overcome CIE challenges.
- Explore key strategies to increase capacity of CBOs in CCO service areas.
CCO community of practice: Deep dive on chart review and claims-based data
- November 19, 2024, 1-2 p.m.
- Audience: CCO measure leads
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Register here
- Discuss how claim-based data and charts review contribute to accuracy of SDOH data collection across clinical settings.
- Collaborate on strategies to integrate claims-based and chart review data into a unified framework for SDOH screening and referral data collection.
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).
2023-24 technical assistance
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.
- 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:
Slides /
Recording
CCO learning collaborative
Audience: CCO measure leads
CCOs will share strategies to address high-priority needs and metric must-pass elements.
- 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
- May 30, 2024 - Addressing referral resources and gaps through use of REALD: Slides /
Recording
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
- 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
2022-23 technical assistance
Recorded webinars
Audience: All CCO staff directly or indirectly involved in implementing the social needs screening and referral metric.
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Community information exchange (CIE) and other platforms (5/30/23) -
Recording /
Slides
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Data collection and sharing (5/2/23) -
Recording /
Slides
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SDOH screening practices (1/30/23) -
Recording /
Slides
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Referral practices and resources (3/28/23) -
Recording /
Slides
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SDOH metric grounding webinar for CCOs and providers (11/8/22) - Recording / Slides
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SDOH metric grounding webinar for CCOs and community-based organizations (11/11/22) - Recording / Slides
Playbook
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.
Resources