Delivering Joined Up Care for Ageing Population with Cellma

In the UK, unmet care needs for older adults remain substantial, around 2 million people aged 65+ require more care and support than they currently receive. 
Long NHS waits, and delayed hospital discharges are increasingly common. Hundreds of thousands are left without adequate support, often “stuck” in hospital while waiting for social care packages to be arranged at home. 

The health demands are immense, 75% of people aged 75+ live with multiple long-term conditions, increasing to 82% for those over 85. 

Even though the NHS Long Term Plan describes a vision for integrated support across the country, there is still widespread inconsistency, delays, and lengthy bureaucratic processes, siloed funding, and workforce development that remains uneven. 

Cellma, a fully integrated and future-facing EHR solution, closes the gap and specifically aligns with NHS goals for ageing well and care that is connected, online, and person-centred.  aligning directly with NHS priorities for ageing well and delivering connected, person-centred care. 

The Current State of Joined-Up Care for Older People 

The NHS Long Term Plan describes a vision for integrated and community-based support; however, many areas currently face: 

Poorly coordinated services – hospitals, primary care, social services and voluntary sector all use different systems that are separate to each other, delaying coordination.  

Discharge delays – medically fit patients remain in hospital as a result of community and social care not being ready to accept them.  

Disjointed information sharing – key patient data is either lost between providers or duplicated.  

Limited rapid-response capability – services don’t have the ability to quickly mobilise teams in order to maintain clients and avoid readmissions.  

For an ageing population, these gaps mean slower recovery, avoidable hospital stays, and declining independence. 

How Cellma Powers True Joined-Up Care 

Cellma is more than an EHR, it’s a fully integrated digital health ecosystem designed to operationalise the NHS 10-Year Plan’s ambitions for connected, patient-centred care. 

Here is how it fits within the clinical workflow of joined-up care for older people: 

1. Hospital Discharge Planning

The hospital clinician’s decision on discharge is instantly recorded in Cellma’s shared electronic health record. So, the day the patient is discharged, the community team, GP and social care providers receive notification, in real time, with no paper delays, to start care at home as soon as the person reaches home. 

2. Coordinated Care planning in the community

Cellma provides a framework for planning home care and district nursing appointments, therapy appointments, voluntary services which can all be managed in one coordinated calendar. 

3. Post Hospital discharge assessments

The initial and subsequent assessments can be added into Cellma which provides GP follow up, as a reminder. All notes, tests results and care plan updates can be accessed at once and in real time, by all health and care providers that the patient has given consent to. 

4. Live care plan and monitoring.

If there is any change in the patient’s health status, the providers in the community can update the live care plan, viewable in real time by multi-disciplinary teams, reducing duplication and ensuring that the team can intervene quickly if needed.  

5. Rapid Response to urgent needs

Rapid Response Teams have access to the most up to date medical records before arriving to see the patient, enabling them to provide informed and considered in-home care that prevents avoidable readmission. 

6. Care Coordination of Care across Settings

Cellma enables care coordinators to manage the entire patient journey — from hospital admission to community-based follow-up — as a seamless digital record. 

7. Integrated Neighbourhood Teams

Primary care, community health, local authorities and voluntary services access the same secure record and can more collaboratively deliver care for patients in their neighbourhoods. 

8. Population Level Frailty Management

Cellma’s advanced analytics can help the organisation identify patients at risk of deterioration and engage in proactive frailty management to reduce dependency on hospital care in the community. 

9. Governance & Shared Outcomes 

Cellma’s reporting dashboards provide ICBs with their live clinical and demographic data and awareness of shared outcomes, e.g., reduction in frailty related admissions, speed of discharge times and independence at discharge rates. 

Virtual Wards & Early Discharge: The Future of Patient-Centred Care 

One of the NHS’s key strategies for joined-up care is the growing use of virtual wards. These allow clinically stable patients to continue receiving hospital-level monitoring and care at home, supported by digital tools and remote clinical teams. 

Equally important is the NHS drive for early discharge planning, where patients are safely discharged sooner, with a coordinated follow-up plan that ensures they do not return unnecessarily to hospital. This not only frees up hospital beds but also improves patient comfort and recovery in familiar surroundings. 

Momentum and Reach 
The NHS are scaling this rapidly, more than 10,000 virtual wards have been adopted in England, with over 15,000 planned as part of the NHS long term plan. Evidence suggests that virtual ward models employed in scale improve patient experience, enable safe discharge, and mitigate demand on hospital beds. 

Evidence of Effectiveness 
Evidence base supports their effectiveness. Evaluations highlight clear benefits: patients in virtual wards stay 3.07 days shorter than patients in hospital on average, and they can free up capacity while underlining the safety models proposed. In Southwest London, 74% of patients discharged to a virtual ward remained at home and not re-admitted into hospital, significant for it’s a real-world achievement! 

Caveats and Considerations 
Virtual wards aren’t universally designed to address everything, they can only improve care when delivered to appropriate patients, to recognise or reduce hospital-related complications, whilst the patient retains their independence at home. 

How Cellma Supports Virtual Wards & Early Discharge 

Integrated Workflows: Automated pathways from inpatient care to virtual ward and alerts with covered handovers. 
Real-time Monitoring: Insights derived from the automatic integration of wearable and at-home monitoring data for a proactive response. 
 
Care Coordination: Every member of the multidisciplinary team with access to and update capabilities within the record to ensure continuity of care in the home. 
Analytics & Risk Stratification: Advanced use of data and analytics to identify those patients who would benefit most from early discharge and virtual ward care. 

Why Cellma is unique for Joined-Up Care 

End-To-End Care Pathway Management: From acute admission to home, and on-going monitoring. 

Patient Portal and Mobile App: Empowering patients and their carers with access to their care plans, test results and appointment booking. 

Comprehensive NHS Integrations: NHS Spine, e-RS, GP Systems, Lab Systems, and Imaging systems. 

Real-Time Data Sharing: So that everybody is working from the latest, trustable information. 

Customisable to Local Needs: Adaptable workflows for different Integrated Care Systems and neighbourhood teams. 

Security and Compliance: Developed for NHS and Global Standards 

Cellma is committed to delivering on the vision for joined-up care, but never at the compromise of patient confidentiality or system integrity. Cellma adheres to and complies with recognised NHS and global security and compliance frameworks, including: 

• NHS Spine – for secure access to national healthcare information. 

• NHS e-Referral Service (e-RS) – for electronic referrals between providers. 

• NHS Summary Care Record (SCR) – ensuring clinicians have essential patient information. 

• GP Connect – enabling real-time access to GP records. 

• Electronic Prescribing Service (EPS) – for prescribing and dispensing medicines digitally. 

• UK GDPR – full compliance for data processing and patient rights. 

• National Health Service Data Security and Protection Toolkit (DSPT) – to the extent required, compliance with NHS information governance obligations.  

• ISO 27001 – certification for information security management systems.  

• HL7 and FHIR – interoperability standards for the exchange of health data between health systems.  

• Role Based Access Control (RBAC) – access to sensitive patient data only to appropriate professionals.  

• End To End Encryption – protecting data in transit and at rest.
     

By adhering to these frameworks, Cellma facilitates the safe and compliant collaboration required for NHS, local authority and voluntary sector organisations to work together, the essential bedrock for achieving effective joined-up care. 

Our ageing population deserves a health and care system that works as one. Cellma is realising the vision for joined up care – breaking down barriers, enabling better communication and collaboration, and ensuring patients receive timely, coordinated and safe support as a patient – wherever they are.  

The NHS 10-Year Plan has set the vision. Cellma provides the platform. 

Let’s make joined up care a reality, together.