ORPRN works with clinics across the state to ensure that every patient seen is routinely screened for health-related social needs, just as they would be for factors like tobacco or alcohol use. Research shows that social needs, like housing instability and food insecurity, have huge impacts on health outcomes. Screening and referring patients to address those social needs can both improve quality of care and reduce health care costs. In a recent evaluation of the Accountable Health Communities Model, total Medicaid expenses decreased by 3% for beneficiaries screened and referred to services.
Unlike screening for traditional health-risk factors, screening and referrals for social needs in clinics requires significant cross-sector collaboration and the bridging of complex systems. ORPRN’s health policy team is leveraging our experience with practice facilitation, quality improvement, and the CCO social needs screening quality incentive metric to support clinics in making large scale systems changes.
Since 2022, our team has called over 15,000 Eastern Oregon Coordinated Care Organization members to screen for food, housing, transportation, utilities, and safety needs, connect them with community resources. In addition to outreach, our team worked with EOCCO to develop and implement a self-referral pathway to more effectively reach members who need help. EOCCO members can now request to be screened and referred on the EOCCO website, and information about this process is being distributed across clinics in their network.
ORPRN also partners with EOCCO and the Oregon Health Authority to support clinics statewide in standing up screening and referral processes. While some clinics face implementation challenges like staffing capacity, feedback on technical assistance has been overwhelmingly positive. Participating clinics are making progress toward their goals, such as improving screening and referral rates, and improving data documentation and reporting in electronic health records and community information exchange platforms.
We are excited to see our efforts result in widespread adoption and scaling of practices. ORPRN’s Claire Londagin, M.P.H. and Mari Tasche, M.P.H., recently presented on these efforts at Oregon Office of Rural Health’s annual Forum on Rural Population Health and Oregon Critical Access Hospital Quality Incentive Workshop. Their presentations provided a systems-level perspective of Oregon’s screening and referral landscape, including a crosswalk of the various quality metrics related to social needs screening and implementation insights from rural healthcare settings.
ORPRN’s health policy and education teams are partnering to offer an ECHO in early 2026 on “Social Needs Screening and Referral in Healthcare Settings”. This community of practice will bring together interdisciplinary experts to support primary care clinics in building processes at patient and community levels. Keep an eye out for registration!
Are you a clinic interested in setting up social needs screening and referrals? Technical assistance is available for clinics interested in setting up screening and referral processes. Contact Sara Wild (wilsa@ohsu.edu) to learn more!
- ORPRN Health Policy Team