Committee votes to implement screening tool to help with patients’ social needs


Shane Ersland


The Oregon Health Authority’s (OHA) Health Plan Quality Metrics Committee will implement a patient screening tool that is designed to help identify and address the various social needs different patients have. Social needs could include food security, housing, and transportation.


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Committee members discussed the tool during a March 29 meeting. OHA Interim Director of Systems Innovation Chris DeMars said several agencies that work with OHA requested the development of a social needs screening tool. The Public Health Advisory Board, the Medicaid Advisory Committee, the Oregon Community Information Exchange, the OHA Ombuds Program, and the Health Equity Committee were all included in discussions about the development of the tool, and expressed interest in using it.

“This has been a long-term effort,” DeMars said. “There have been quite a few conversations. We listened to partners and community members to develop the measure. The goal of the measure is to get people’s social needs addressed. This is about the end goal, not just about the screening; incentivizing a system to make sure they get social needs addressed.”

OHA Quality Metrics, Surveys, and Evaluation Manager Kate Lonborg said that the first few years the tool is in place will be used to develop structural components. To build system capacity, the tool will require coordinated care organizations to prepare for equitable screenings and referrals. It will utilize data sharing, identify screening tools or questions to be asked of patients, and establish protocols to prevent over-screening. Key focuses of the tool will include food security, housing, and transportation.

Lonborg was asked about closed-loop referrals, which provide a way for health care professionals to send patient information to a community-based organization to help address a patient’s needs. She said closed-loop referrals could be utilized under a long-term plan, but not immediately after its implementation.

“There was discussion to get closed-loop referrals,” Lonborg said. “It didn’t seem feasible to go directly to them. Part of it is thinking about what the referral pathways are. We’ve heard from patients and community groups that this is beneficial. We also did pilot testing in 2021, and heard good feedback on the measure’s feasibility.”

Committee members unanimously voted to implement the tool with 10 votes. It will be ready for use in 2023.