January 28, 2010 Information and Grants Manager Richard King Mellon Foundation BNY Mellon Center 500 Grant Street, Suite 4106 Pittsburgh, PA 15219-2502 Attention: Lisa Reed Dear Ms. Reed: Thank you for the opportunity to present MISSION: LIFELINE – a community-based initiative to improve the quality of care and outcomes in heart attack patients and to improve health care system readiness and response. More than 1.5 million people living in the U.S. suffer some form of cardiac arrest every year, and approximately 400,000 of those are victims of the deadliest form of heart attack, ST-Elevation Myocardial Infarction, or STEMI. Some die because, too frequently, they don’t recognize the symptoms. Others who might recognize the symptoms die because they delay seeking medical help for a variety of reasons. The time-related risks facing STEMI patients are formidable. The path to STEMI treatment is not always a direct one, and delays along the way can result in devastating quality-of-life repercussions resulting from cardiac tissue damage/loss of functions for survivors. The time continuum to secure favorable outcomes for STEMI victims includes:

• the patient’s prompt recognition of symptoms • the patient’s immediate call for medical help • rapid identification/confirmation of STEMI by 12-lead ECG • timely treatment to restore blood flow

Given the variables on the patient side of the continuum and the unpredictable nature of the time required for decision-making on the treatment deliver (hospital) side, the pivotal advantage provided by pre-hospital 12-lead diagnostics can’t be overstated. But, it will take the consensus of all of the appropriate stakeholders in the STEMI chain of survival to build a better environment for the care and safety of STEMI patients. With your financial support, the American Heart Association and our strategic partners will work together to this end.

On behalf of our collaborative partners, the American Heart Association is requesting your support in the amount of $500,000 for Mission: Lifeline, an initiative that will provide a lasting contribution to our community. We are attaching our proposal which outlines some of the important considerations. However, we would welcome the opportunity to meet with you to provide additional information. Thank you, in advance, for your favorable consideration of MISSION: LIFELINE. Sincerely, Phyllis Kokkila Director of Donor Relations American Heart Association Great Rivers Affiliate 777 Penn Center Blvd., Suite 200 Pittsburgh, PA 15235 Direct: 412-702-1127 Cell: 412-860-7681 Fax: 412-824-3934 Email: phyllis.kokkila@heart.org Cc: Michael Watson

Table of Contents

Common Grant Application Mission: Lifeline Proposal

• Mission Lifeline Proposal • List of Commonly Used Terms • PA Map

Addendum

• Public Awareness Campaign Discussion • Press Release • Equipment and Transmission Discussion

Financials

• Budget • IRS tax determination letter • Audited Financial statement

Letters of Support:

• Donald R. Fischer, MD, Senior Vice President, Chief Medical Officer, Highmark

• J. Harper, President, Hospital Council of Western PA • Story of Paul Treml with letter from Colleen Treml, wife of survivor

Leadership and Partners

• Pennsylvania Mission Lifeline Steering Committee • Representative listing of Pittsburgh Strategic Partners • Allegheny Division Board of Directors • Westmoreland Division Board of Directors • Key Staff Biographies • Mission: Lifeline Director Job Description

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Overview Mission: Lifeline is a community-based initiative to improve the quality of care and outcomes for heart attack patients and to improve health care system readiness and response. Through Mission: Lifeline, the American Heart Association will act as the patient advocate to convene the necessary stakeholders who will create a new set of best practices for care of the victims of the deadliest type of heart attack, ST-Elevated Myocardial Infarction (STEMI). A patient experiencing a STEMI heart attack has less than two hours to receive treatment or they are likely to experience significant heart damage, full cardiac arrest, or death. Balloon angioplasty is the preferred method of treatment and 100% effective in removing the blockage. However, only select hospitals can perform this procedure and few are available twenty-four hours a day, seven days a week (24/7). The national average for receiving this treatment is 149 minutes or two and one half hours. Funding for Mission: Lifeline will support the resources needed to convene a strategic and collaborative stakeholder group, market the messages surrounding STEMI care, and reinforce the best practices developed at the community level for consistent healthcare. It will also fund the training required for use and transmission of Electrocardiograms (ECG) secured through the use of 12-lead equipment as well as training necessary for proper entry of data into the Action Registry/Get With The Guidelines database. Action Registry/Get With The Guidelines will be used for data collection, tracking, and quality improvement (12-Lead ECG equipment is the first line of defense in identifying the STEMI event). Trauma patients already benefit from collaborative efforts to improve systems of care. Paramedics and medical professionals know exactly what to do for a head injury, for example, because a system is in place for Trauma. The AHA wants a similar experience for treating victims of heart attack. Improving the timely system of care will not only save lives, but will also address a serious health care concern – the incidence and long term consequence of heart failure. There are more than five million people with heart failure issues, affecting not only their quality of life, but also costing an estimated $34 billion annually to society. In Western Pennsylvania, there were 17,191 cases, with an average cost of $16,780, for a total cost of approximately $288,464,980. The American Heart Association reported in 2009 that approximately 151,000 individuals died from myocardial infarction. The estimated average number of years of life lost because of myocardial infarction is 15. Compounding the problem, 50% of men and 64% of women who die have no previous symptoms. Within two hours of symptom onset, 50% of individuals with myocardial infarctions have sudden cardiac death. Mission: Lifeline has significant potential ramifications for our community in terms of health and annualized costs for lost time from employment, the cost of disability and health care, and productivity. The estimated national direct costs (inpatient hospitalization, pharmaceuticals) and indirect costs (lost productivity, time away from work) associated with severe cardiac arrest ranged from $1,001,493 to $1,051,302 per case. The average lifetime cost of less severe coronary disease is estimated at $767,288 per instance. When Mission: Lifeline is fully implemented in Western Pennsylvania it could save 500 lives annually.

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Mission: Lifeline’s guiding principles: The initiative values: • Patient-centered care as the #1 priority • High-quality care that is safe, effective and timely • Stakeholder consensus • Increased operational efficiencies • Appropriate incentives for quality

• Measurable patient outcomes • An evaluation mechanism • A role for local community hospitals • A reduction in disparities of healthcare delivery

Mission: Lifeline will: • Promote the ideal STEMI systems of care

• Help STEMI patients get the life-saving care they need in time

• Bring together healthcare resources into an efficient, synergistic system

• Improve overall quality of care The initiative is unique in that it: • Addresses the continuum of care for STEMI patients • Preserves a role for the local STEMI-referral hospital • Understands the issues specific to rural communities

• Promotes different solutions/protocols for rural vs. urban/suburban areas

• Recognizes there is no “one-size-fits-all” solution • Knows the issue of implementing national

recommendations on a community level Problem and Need Every year, almost 400,000 people in the United States experience STEMI attacks. Unfortunately, a significant number do not receive prompt reperfusion therapy, which is critical in restoring blood flow. Worse yet, 30 percent of STEMI victims who are eligible for treatment do not receive any treatment at all. There are two methods of treatment for STEMI heart attacks. The American Heart Association and American College of Cardiology guidelines recommend that patients with STEMI receive angioplasty or percutaneous coronary intervention (PCI) within 90 minutes of first medical contact (either emergency medical services or hospital) or fibrolytic therapy (clot busting drugs) within 30 minutes. Angioplasty is a procedure used to open or widen narrowed or blocked blood vessels supplying the heart and is the treatment of choice for patients with STEMI. Unfortunately, these recommended standard times are currently not being met. The national average time for a patient to receive balloon angioplasty is 149 minutes (or two and one half hours). The Pittsburgh region hospitals reported to Medicare in 2007 that that only 60% of patients received PCI within 90 minutes. Within 2 hours of symptom onset 50% of patients will suffer sudden cardiac death. (PCI is a procedure used to open or widen narrowed or blocked blood vessels supplying the heart, commonly referred to as balloon angioplasty.) The outcomes also support the recommendation for balloon angioplasty. In Western Pennsylvania, the mortality rate was significantly higher for those who only received medical management, 534 deaths or 12%, as compared to those who received balloon angioplasty, 61 deaths or 1%.

What is STEMI? ST-Elevation myocardial infarction (STEMI) is a completely blocked artery which stops the flow of blood and oxygen throughout the body. With this type of complete blockage, time to care is vital as the heart muscle actually starts to die. After two hours, a person with this condition is almost certain to either pass away, or is left with serious heart failure issues for the remainder of their lives. The quicker the artery is opened – the less muscle is lost. Time is muscle!

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STEMI Chain of Survival

Importance of Dealing with STEMI Care ST-Elevation myocardial infarction (STEMI), the most severe form of acute coronary syndromes (ACS) short of sudden cardiac death, is a significant public health problem with an estimated 400,000 STEMI events every year in the United States (US). The American Heart Association reported in 2009 that approximately 151,000 individuals died from myocardial infarction. The estimated average number of years of life lost because of myocardial infarction is 15. Compounding the problem, 50% of men and 64% of women who die have no previous symptoms and within two hours of symptom onset 50% of individuals with myocardial infarctions have sudden cardiac death. 69% of these deaths occurred out-of-hospital. Early presentation and rapid diagnosis are paramount to obtaining optimal timely treatment following the onset of STEMI. Among these individuals, the risk of another cardiac event is substantial. Within five years of a STEMI heart attack, 15% (white men age 40-69 years) to 62% (black women 70 years old and older) of individuals will die.

Barriers to Timely Reperfusion There are several barriers to timely reperfusion:

The patient • Failure to promptly recognize symptoms • Hesitation to seek medical attention – and call 9-1-1

Time to transport

• Mandated delivery to the closest hospital, regardless of PCI capabilities • Long transport in rural areas

Decision process on arrival

• Clot busting drugs vs. PCI • Off hours • Transfer to PCI facility

Time to implement treatment strategy

• Procedural factors • Communication between first responders and hospital • Team assembly

History of AHA’s Recommendation to Develop Strategi es to Increase the Number of ST-Segment-Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary Intervention In 2004, Dr. Alice Jacobs, Director of Cardiac Catheterization Laboratory and Interventional Cardiology at the Boston Medical Center and then National American Heart Association President, made STEMI systems part of her platform. Since then there have been four different pilot projects in

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the United States. It is through these pilots that we know it is possible to accomplish the goals of Mission: Lifeline. For example, the pilot in Boston has experienced a 15-20 minute improvement in median Door to Balloon time. The North Carolina pilot, RACE, also showed significant improvement in care after transport. The director of RACE, Mayme Lou Roettig, RN, MSN joined the American Heart Association as a National Consultant for Mission: Lifeline. Ms. Roettig’s experience and leadership will be invaluable to this initiative. History 2004-2007

May 2004 • AHA recruited an Advisory Working Group (AWG)

June 2005

• PriceWaterhouseCooper presents its market research to AWG

March 2006

• AWG Consensus Statement appears in Circulation

• Stakeholders called to action • AWG develops a set of guiding principles • AHA held a conference of

multidisciplinary groups involved in STEMI patient care

Early 2007

• Drafts of STEMI Systems of Care manuscripts are finalized • Action items for the AHA begin to take shape

April 2007

• A cross-functional team was recruited to spearhead Mission: Lifeline May 2007

• Eleven manuscripts are published in Circulation • Mission: Lifeline was formally launched

Why the American Heart Association? While all of the appropriate stakeholders are interested in the best patient care, cardiac care is one of the largest revenue sources and therefore a sensitive issue to address. The American Heart Association is uniquely positioned as the patient advocate, without any financial interest or agenda. In addition, the American Heart Association has long-term collaborative relationships with the stakeholders necessary to convene to address STEMI system of care. The American Heart Association was founded in 1924 when six cardiologists wanted to determine if a person could go back to work after experiencing a heart attack. Since that time, research has been a driving principle of the association. It has funded more than $3 billion in research, including $1 billion in the last decade. While our funding has focused on early career investigators, to help establish the careers of some of the best young minds in the country and encourage new discovery, it has also funded 11 Nobel Prize winners with three of them being selected in the last six years. We have seen

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tremendous advancements in cardiovascular care, many of which were funded by AHA, like pacemakers, CPR, stents, valve replacement and repair, hypertension, cholesterol, and congenital heart disease. In Western PA, $1.9 million AHA funding is supporting the work of 58 scientists. Our research/science acts as a guideline for projects and initiatives to be implemented at the community level.

Science has been and remains the driving force behind our mission, “building healthier lives, free of cardiovascular diseases and stroke.” The American Heart Association has the experience and credibility required to be successful. AHA has a long history of collaboration. As early of the 1940s, AHA convened 12 other health-related organizations and three nations to wage a fight against rheumatic fever. As a more recent example, six years ago we implemented a system, similar to what we want to accomplish for heart attacks, for Stroke Care. This initiative revolved around time to care for stroke victims and required convening of a very similar audience to create best practices. We then collaborated with the Joint Commission on Accreditation to create what are now regulations for Hospital Accreditation in stroke.

AHA created the first guidelines for cardio pulmonary resuscitation (CPR) in the 1960s and now produces guidelines in 18 different countries and 16 different languages in addition to the United States. We have had ongoing relationships with Emergency Medical Services for the last four decades. In Western Pennsylvania, we have relationships with all of the major hospitals, and have been involved in quality improvement through our Get With The Guidelines product.

Organizationally, the American Heart Association has communication departments to help distribute the messages to the community, development personnel to assist in raising necessary funds, and advocacy personnel to work with state and local governments should regulatory issues become part of the initiative.

In our community today, AHA knows that it will be more effective reaching out to stakeholders to accomplish our goals.

Partners for Success • Patient and care givers • EMS providers • Physicians, nurses and other providers • STEMI-referral (non PCI) hospitals • STEMI-receiving (PCI-capable) hospitals • Health system

• Departments of Health • EMS regulatory authority/office of EMS • Rural health associations • Quality improvement organizations • Third-party payers • State and local policymakers

Ideal STEMI System of Care

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Project Description and Methodology The funding for Mission: Lifeline will support the necessary resources needed to convene the stakeholder group, market the messages surrounding STEMI care and to reinforce the best practices developed at the community level for consistent healthcare.

It will also fund the training necessary for emergency first responders to read 12-Lead ECGs. The 12-Lead ECG is the device that will be used to diagnose the difference between a heart attack and a STEMI heart attack. Prior to our early preparation for Mission: Lifeline, there were two data collection systems widely used in the healthcare industry. The first was the American College of Cardiology’s Action Registry (Action). The second was the American Heart Association Get With The Guidelines (GWTG). Approximately 40-45% of hospitals were using GWTG to track their internal best practices. Because Mission: Lifeline is a priority for our communities, the American College of Cardiology combined their Action system with GWTG to encourage wide-scale use throughout the nation. Data will be entered into Action Registry/Get With The Guidelines for tracking to provide the information to track results and for further system improvement.

Implementation Framework Successful implementation of a STEMI system in Western Pennsylvania depends on many factors and the involvement of many participants in the process. The American Heart Association will work to create an environment that is cooperative and in which there is a partnership among all EMS, hospital, providers, and community. The key to successful administration will be the ability of the American Heart Association to build a STEMI system based on available resources, provider and community commitment, and ongoing evaluation. Overall implementation of the STEMI system will involve setting realistic timeframes for each component, as well as establishing a system for managing and reviewing the process itself. Below is the implementation framework that describes some of the key implementation activities that will be accomplished as part of the Mission: Lifeline initiative in Western Pennsylvania. Leadership and Coordination In developing and organizing the Western Pennsylvania regional STEMI system, the American Heart Association will coordinate both EMS and hospitals, seek input from key participants at each phase of development and will negotiate workable policies. The AHA will organize and manage the Western Pennsylvania Mission: Lifeline Steering Committee composed of pre-hospital and hospital providers from all levels of STEMI care to guide system planning activities. The Steering Committee will be comprised of a multidisciplinary group of providers and consumers (including previous STEMI patients and their families where possible) whose interest and expertise can facilitate the development and implementation of the Pennsylvania statewide STEMI system. Activity Timeline Outcome • Identify Western Pennsylvania Mission: Lifeline Steering

Committee chairperson and co-chairperson Year 1 Chair/co-chair recruited

• Identify and recruit key stakeholders and strategic partners to participate on Western Pennsylvania Mission: Lifeline Steering Committee

Year 1 Stakeholder/strategic alliances recruited

• Develop structure, roles, responsibilities and expected outcomes of Western Pennsylvania Mission: Lifeline Steering Committee

Year 1 Committee organization and management plan developed

• Conduct meetings on at least a quarterly basis of Western Pennsylvania Mission: Lifeline Steering Committee

Ongoing 4 meetings per year

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Leadership and Coordination continued Activity

Timeline

Outcome

• Possibly establish a local task force to address and enforce cohesive messages between Public Education/Information and Prevention, Emergency Medical Services and/or Hospitals.

TBD TBD

Pre-hospital Pre-hospital care is a vital component of the STEMI system; what happens in this setting often directly impacts both initial treatment and eventual outcome. Pre-hospital care includes medical dispatch, first responders, basic life support, and advance life support providers and medical direction. Elapsed time between symptom onset and receipt of definitive care is dependent upon: 1) public recognition of the event; 2) access to the EMS system (i.e. 911); 3) response time performance of the EMS system; 4) equipment, level of training and performance on-scene; and 5) distance to appropriate definitive care. The Western Pennsylvania Mission: Lifeline initiative will look to increase coordination among these segments. This may include changing State and/or regional regulations for personnel and equipment, treatment protocols and transport criteria which match patient severity to hospital capability/capacity and determine transport decisions. Activity Timeline Outcome • Assess current EMS transportation resources and

describe their current configuration, including vehicles, equipment deployment methodology(s), and transportation/destination protocols. Identify the strengths and weaknesses of the current system(s)

Year 1 Written assessment

• Document commitment of EMS systems to participate in the STEMI system through signed memorandum of understanding

Year 1 Number of Memorandums of understanding signed

• Identify and implement strategies to strengthen the existing EMS to hospital transportation system and ongoing mechanism for evaluation

Year 1, 2, 3 Number of cath lab field activation false positives

• Implement continue education programs Year 1, 2, 3 Number of certificates issued

• Develop and implement STEMI screening tools and fibrinolytic checklist (have not previously defined fibrinolytic)

Year 1 Number of EMS systems using screening too and fibrinolytic checklist

• Develop and implement strategy to provide ongoing feedback to EMS providers who care for and transport STEMI patients

Ongoing Number of hospitals implementing feedback strategy

• Assist EMS systems with identifying funding and submitting requests for equipment

Ongoing Number of EMS systems of 12-lead equipment

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Hospital It is imperative that STEMI patients are delivered in a timely manner to the closest appropriate facility-preferably a hospital that performs primary PCI (angioplasty). Regionalization of STEMI care involves the participation of hospitals with the resources necessary to provide optimal care for STEMI patients and the identification of the specific capabilities of each facility. An essential part of the Mission: Lifeline initiative is the regionalization of care and system integration. The Western Pennsylvania Mission: Lifeline initiative will work to integrate all hospitals into an inclusive network of hospital providing a tiered response to meet the needs of STEMI patients. The regional STEMI network will reflect the individual needs of the community it serves. Activity Timeline Outcome • Assess hospital capacity and describe capabilities

including institutional resources and ability to meeting program requirements (protocols, facility volume, operator proficiency, 24/7 capability, current quality improvement, etc.)

Year 1 Written assessment

• Document commitment of hospital to participate in the STEMI system through signed memorandum of understanding

Year 1 Number of Memorandums of Understanding signed

• Implement ARG (Action Registry - Get With The Guidelines) in hospitals

Year 1, 2, 3 Number of hospitals participating in Action/Get With The Guidelines

• Conduct Quality Improvement workshops on STEMI Year 1, 2, 3 Number of workshops and number of attendees

• Facilitate implementation and/or enhancement of QII programs to improve care for STEMI patients throughout the continuum of hospital care (acute and secondary prevention)

Ongoing Number of hospitals participating Number of hospitals receiving Silver and Gold recognition

• Implement continue education programs Year 1, 2, 3 Number of certificates issued

• Develop and implement algorithms for standardized treatment protocols and clinical pathways in emergency departments and STEMI referral and receiving hospitals according to ACC/AHA guidelines

Year 1, 2, 3 Number of hospitals implementing standardized protocol

Public Information/Education and Prevention Cardiovascular disease is a preventable public health problem and a well-planned community public information/education and prevention program is an integral part of an effective STEMI system. The American Heart Association, with our partners, will develop and implement a program to educate the public about signs and symptoms and the importance of calling 911. This campaign will be designed to overcome and reduce barriers to activating EMS by illustrating the differences in care provided by hospitals (PCI versus non-PCI) in emergency cardiac event occurrences. Activity Timeline Outcome • Assess current STEMI and cardiovascular disease

prevention programs and resources Year 1 Written assessment

• Develop a plan to heighten public awareness of STEMI as a public health problem including additional strategies needed to target hard to reach or high risk populations

Year 2 Written plan

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Public Information/Education and Prevention continued Activity

Timeline

Outcome

• Establish a local constituency to promote STEMI awareness and prevention activities

Year 2 Number of community educators

• Implement comprehensive (e.g., mass media, community programming, social media, etc.) public education/information activities – may include pilot testing national strategy

Year 2-3 Number of media impressions, number of community education events, etc.

• Educate local elected officials about STEMI system issues

Year 2-3 Number of elected official educated

Measures The American Heart Association has completed four pilot projects: Los Angeles County, North Carolina, Boston and Minneapolis. As a result, it is clear that each community has some primary measurements in common, but due to their unique challenges and community characteristics they have different secondary measurements. Many of these measurements have national averages. The exact measurements for Western Pennsylvania will be established during the first year of the program.

Primary Measures

1. Percentage of patients who arrive via ambulance This is the fastest way for patients to present for treatment and will be influenced by multiple aspects of the project. National Baseline: 50% of people present in this manner. Goal: 10-15% increase or a target of 85% if Western Pennsylvania specific measurement is significantly higher than the national average. 2. Percentage of patients who receive angioplasty within 90 minutes of entering the hospital (Door to Balloon time < 90 minutes) This is the primary measure of success for the hospitals that can implement angioplasty. There is a door to needle time for administration of the clot busting drug, but the goal of this project is to lower the incidence of that treatment. National Baseline: 60-65% of people receive angioplasty in this timeframe. Goal: 10-15% increase or a target of 85% if Western PA specific measurement is significantly higher than the national average. 3. Percentage of transfer patients who receive ang ioplasty within 90 minutes of entering the hospital (Door to Balloon time < 90 minutes) While one of the goals of Mission: Lifeline is to limit the amount of people who need transfer, there will always be some cases where patients present themselves to a hospital that cannot do angioplasty. This is the most difficult part of the program that Mission: Lifeline will address. National Baseline: 18% of people receive angioplasty in this timeframe. Goal: 10-15% increase for this measure. 4. The median time for patients to receive angiopl asty within 90 minutes of entering the hospital (Door to Balloon time) While the current measure is that Door to Balloon should be done in 90 minutes, research has shown that 60 minutes are actually preferred for the best patient care. National Baseline: The National median Door to Balloon time is 65-70 minutes. Goal: 10-15% reduction for the Pittsburgh region or a target of 60 minutes.

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This project will create a second measure for Western PA often referred to as first medical contact to balloon (angioplasty) time. There are several different opinions as to what is first medical contact. This will be defined and the measurement fully defined. 5. In-hospital risk-adjusted mortality for STEMI p atients in System Longitudinal outcome: 30-day, 1-year mortality. Over time, we will likely select whether the 30-day or 1-year mortality rate is a better overall measurement. National Baseline: There is no National Baseline. Goal: Reduce the mortality rate by up to 3%. While there is no National Baseline, it has been estimated that 400,000 people experience STEMI heart attacks per year. A 3% decline would save 12,000 people per year on a National basis.

Geographic Area While the service area will be determined as part of the project, currently there are natural partners within an approximate 60 to 75 mile radius of Pittsburgh for the transfer of patients. It is our intention to leverage the existing collaboration to build the best system of care for Western Pennsylvania. Geographically we anticipate that the region will extend from the south at approximately the West Virginia border to the north just short of Erie. The natural partners continue into the central mountains and end near I-80 toward the center of the Commonwealth.

Mission: Lifeline’s Significance to Our Aging Popul ation Creating a STEMI system of care will have significant benefits in our community. While you can experience a STEMI heart attack in your early 40s, more than 50% of patients are over the age of 60 with the average age of patients nationally ranging from 62-68. Depending on their gender and clinical outcome, people who survive the acute stage of a heart attack have a chance of illness and death that is 1.5-15 times higher than that of the general population. The following are mortality rates within one year following this type of heart attack for people over the age of 70:

• 27 percent for Caucasian men • 32 percent for Caucasian women

• 26 percent for African American men • 28 percent for African American women.

The mortality rates rise even higher within five years for people over the age of 70:

• 50 percent for Caucasian men • 56 percent for Caucasian women

• 56 percent for African American men • 62 percent for African American women.

Program Sustainability This initiative is designed to change and improve the protocols and best practices for the healthcare providers and emergency services in the area. As part of their desire to provide the best possible care, these entities depend on strict policies to drive their programs and service to create sustainable processes and continual improvement. The Action/GWTG system will track these results even after the three year project has been completed. This measurement will assist in reinforcing the best practices. It will take significant collaboration to make the necessary changes in the STEMI system of care. Once this program has been implemented, the system will serve the Western Pennsylvania region for many years. Budget A budget with budget assumptions is attached Please join us in this important project We respectfully request your consideration of our request for financial support of Mission: Lifeline.

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Funding to date To date we have received $100,000 from The Pittsburgh Foundation and $120,000 from the Highmark Foundation We have submitted requests to both the Jewish Healthcare Foundation and to DSF Foundation. Both organizations requested that we submit our total need for review. The DSF Foundation Board of Trustees has invited us to be present to answer additional questions on April 29, 2010. Jewish Healthcare will present our request to their Board in April. We are in the process of discussions with other funders and will report the progress of these discussions and invitations to submit. Thank you. List of attachments: IRS tax determination letter Audited financial statement Budget Board of Directors List

• Great Rivers Affiliate, Allegheny Division • Great Rivers Affiliate, Westmoreland Division

Mission Lifeline Director Job Description Key Staff Biographical information List of Commonly used terms PA Map Letters of Support:

• Donald R. Fischer, M.D., Senior Vice President, Chief Medical Officer, Highmark • A.J. Harper, President, Hospital Council of Western PA • Colleen Treml, wife of survivor

Pennsylvania Mission Lifeline Steering Committee Representative listing of Pittsburgh Strategic Partners