The Care Connect Community EMS Program is a voluntary, home‑based health service run by Cross Plains Area EMS to support patients with ongoing medical or social needs and to reduce preventable 9‑1‑1 calls and emergency room visits. It serves eligible residents within the Cross Plains Area EMS district, including the Village of Cross Plains, Town of Cross Plains, Town of Berry, and portions of the Town of Springfield. 

What Care Connect Is

Care Connect is a community EMS program that brings a trained EMT or paramedic to you for scheduled visits at home or in the community, rather than only during emergencies. The focus is on helping people manage chronic health conditions, prevent falls and other emergencies, and get connected with the right medical and community resources. 

The program is especially designed for:

• People who call 9‑1‑1 frequently or have recently been in the hospital and are at risk of going back. 
• Older adults, people with chronic conditions like heart failure, COPD, diabetes, or high blood pressure, and those with complex medical or social needs. 
• Individuals with behavioral health needs or who are receiving palliative or hospice care and would benefit from extra support and coordination. 

Participation is completely voluntary, and leaving the program does not affect your ability to receive regular emergency 9‑1‑1 services. 

How the Program Helps Patients

During scheduled visits, Care Connect providers offer a mix of clinical checks, education, and care coordination tailored to each patient. 

Typical services include:

• Health assessments and vital‑sign checks (blood pressure, oxygen level, weight, blood sugar when appropriate). 
• Medication review to look for duplicate, expired, or missed medications and to help you understand how and when to take them. 
• Chronic disease monitoring for conditions such as heart failure, COPD, diabetes, high blood pressure, and behavioral health concerns. 
• Fall‑risk and home‑safety checks, including looking for trip hazards, checking smoke/CO detectors, and discussing emergency access to the home. 
• Screening for social needs such as food, housing, transportation, utilities, and caregiver stress, with referrals to local resources when needed. 
• Health education and coaching to help you understand your conditions, warning signs, and when to call your doctor versus 9‑1‑1. 
• Coordination with your primary care provider and other members of your care team so everyone is on the same page, especially after hospital visits. 

Care Connect does not replace your doctor or clinic, and it does not take the place of calling 9‑1‑1 in an emergency. If a serious problem is found during a visit, the provider can activate 9‑1‑1 and begin appropriate care while an ambulance responds. 

How the Process Works

The Care Connect workflow is structured into clear phases from referral through “graduation.” 

1. Referral received
   A referral is sent to Care Connect—usually from your doctor, hospital, or another medical provider—along with basic information about why the program may help you. Referrals can also come from social services, law enforcement, behavioral health, family or caregivers, and, in some cases, directly from the patient. 
2. Initial contact and eligibility
   The Care Connect Coordinator contacts you or your family, typically within 72 hours (24 hours for urgent referrals), to explain the program and see if you are interested. If you agree to talk, the team reviews simple eligibility criteria focused on your health conditions, use of 9‑1‑1, recent hospital stays, age, or ongoing behavioral/palliative needs. 
3. Enrollment and consent
   If you meet criteria and want to participate, you sign a consent form that explains the program, your rights, and how your health information may be used and shared to coordinate your care. Participation is voluntary, you may withdraw at any time, and you will still have full access to emergency EMS services. 
4. Initial assessment visit
   Within about seven days, an EMT or paramedic visits you at home for a comprehensive assessment. This includes vital signs, medication review, evaluation of daily functioning, fall risk, behavioral health screening as appropriate, and a home‑safety assessment. 
5. Personalized care plan
   Based on this first visit, the Care Connect team develops an individualized care plan with specific goals, visit frequency, and referrals to community resources as needed. This plan is shared with your primary care provider within about 14 days so they remain involved and informed. 
6. Ongoing visits and follow‑up
   Visit schedules are based on your risk level—for example, weekly at first for higher‑risk patients, then less often as things stabilize. At each visit, the provider checks your vital signs, reviews medications, monitors progress toward your goals, and addresses new concerns or unplanned ER/EMS visits. 
7. Reassessment and graduation
   At regular intervals, the team reassesses your progress to decide whether to adjust visit frequency, add supports, or begin transitioning you out of the program when your goals are met. Patients may “graduate” when their condition is stable, may be discharged for administrative reasons (such as moving out of the district), or may withdraw from the program at any time by request. 

Throughout this process, all visits are documented in the EMS electronic record system, and summaries are shared with your primary care provider so your whole care team stays aligned. 

Eligibility, Referrals, and Coverage

Care Connect is available to residents within the Cross Plains Area EMS district: the Village of Cross Plains, the Town of Cross Plains, the Town of Berry, and portions of the Town of Springfield. The program focuses on patients who are at higher risk due to frequent EMS use, recent hospitalizations, chronic conditions, fall risk, complex social needs, behavioral health concerns, or palliative/hospice care. 

At this time:

• Referrals are generally made through your doctor, clinic, hospital, or another medical provider who believes you would benefit from extra support at home. 
• Care Connect can also accept referrals from social service agencies, law enforcement, behavioral health providers, family members, or the patient, but medical providers remain central to coordinating care. 
• Program visits may be covered by participating insurance carriers; details are coordinated during enrollment and through your referring provider or primary care clinic. 

If you think Care Connect might be helpful for you or a family member, the easiest first step is to talk with your primary care provider or hospital care team and ask them to send a referral to Cross Plains Area EMS using the Care Connect referral forms.