Three New Features to Enhance Continuity of Care After Hospitalization

At HF Software Solutions, we are dedicated to understanding the practical needs of our clients and using their feedback to drive improvements. Recently, we had the opportunity to design three new features based on client feedback that we are excited to share! These new features are intended to support continuity of care after hospitalization and are immediately available to all clients using the HealthFocus platform.


The Continuity of Care Document (CCD) represents a patient’s medical history and condition. It can include the history of present illness, medications, vital signs, labs, care plan, and more. The data within a CCD is exchanged via C-CDA (Consolidated Clinical Document Architecture), a machine-readable HL7 format.

NEW FEATURE: The CCDA is now immediately available to providers from the HealthFocus dashboard.

To access this feature, scroll down to the Transitions of Care section at the bottom of the dashboard. This section provides a view of patient admission, discharge, and transfer (ADT) events for the past six months for patients you are authorized to see. At the top of the section, locate the column titled CCDA. Each row in this column represents an individual patient. By clicking on the view icon, a new tab will open, displaying the CCDA for that specific patient. Providers can also choose to download the document for reference.

BENEFITS: Having direct access to the CCDA allows providers to reconcile medications and prepare for any appropriate follow-up office visits ahead of time to make patient care more efficient.

Annual Wellness Visits

To increase participation in preventative care measures, some payers attach incentives to specific targets such as annual wellness visits. This target is tracked as the number of compliant patients over the total number of eligible patients. The product is a percent of the entire patient population who have met the criteria for this measure. Once a certain percent of the patient population shows as compliant, providers qualify for an incentive payment.

NEW FEATURE: Interactive toolbar for annual wellness visits for Medicaid

To access this feature from the homepage, navigate to the “Trackers” menu in the page header and select annual wellness visit from the drop-down list. Selecting this measure will bring you to a list of Medicaid patients. At the top of this page, there is a toolbar that displays the number of ineligible, eligible, scheduled, and completed patients. This toolbar also functions as a quick filter. Each segment can be selected and will navigate to a corresponding patient list.

BENEFITS: Providing a visual representation of compliance with this measure can help prompt providers and office staff to schedule in-office visits for eligible patients and close gaps towards incentive payments.

Measure History

NEW FEATURE: Patient measure history

You can now access a measure history from any patient list by clicking the list icon under the measure history column. Here, users can view information, including procedure/lab codes, where the measure originated from, and the completion date.

BENEFITS: A full measure list helps provide a more detailed picture of longitudinal care. Users can more easily identify trends in results or check compliance with a measure against specific components of patient care.

Physicians have been using HealthFocus to improve patient outcomes for over ten years. We enjoy working with our clients to continuously update the platform to reflect current trends and requirements in the healthcare market. These new features will help enhance user capabilities and aid in coordinating care for patients following hospitalization.


To learn more about HealthFocus, visit our website, To learn more about our client experiences, you can read our case studies from Huron Valley Practice Affiliates, Ascension St Mary’s PHO, and Great Lakes PO.

James Morris, CEO