An innovative stroke care model at Health Sciences North (HSN) is changing the game for stroke patients in the Sudbury District, offering faster access to care and fewer hospital admissions with an aim of easing pressure on a stretched healthcare system.
The MObile TIA and Stroke with AdaptiVE Workflow (MOTIVE) project brings an expert team directly to patients — wherever they are in the hospital — for early assessment, co-ordinated treatment planning, and streamlined access to rehabilitation. A stroke happens when blood stops flowing to a part of the brain, or bleeding occurs in the brain, leading to the death of brain cells.
“This is a paradigm shift,” said Venkadesan Rajendran, who is the MOTIVE Project Lead. “Instead of waiting for patients to be transferred to the designated stroke unit, we bring the care to them. We're reducing the time lost due to system inefficiencies.”
The mobile team includes stroke neurologists/stroke physicians, an advanced practice physiotherapist, an occupational therapist, a stroke nurse, a speech-language pathologist, and a reactivation worker. This team assesses patients in the Emergency Department and those who have been identified on other non-stroke units, such as patients who have sustained a stroke while in hospital for surgery or cancer treatment.
“Traditionally, our acute stroke care is provided on the fifth floor, the Acute Stroke Unit. Now, our interdisciplinary team is mobile and can provide stroke expertise to the other units,” said Lisa Zeman, Clinical Manager. “We’re able to start the assessments in the Emergency Department, or ICU or other units and support discharge planning sooner. In some cases, we can even help patients avoid hospital admission altogether.”
“We’ve had patients with mild strokes or TIAs (transient ischemic attacks) who previously would have been admitted for several days,” said Dr. Ravinder-Jeet Singh, HSN Stroke Neurologist and principal investigator of the MOTIVE project at HSN. “Now we see them, assess them, get their MRI, and refer them to outpatient therapy, all without needing a hospital bed.”
Team-based care and collaboration
Rajendran said the project incorporates an advanced practice physiotherapist (APP) in stroke care that HSN introduced a few years ago. Being able to work within their full scope of practice, the APP can effectively evaluate stroke patients and collaborate with stroke doctors and interdisciplinary teams to determine the necessary recovery plan.
HSN has become a leader in establishing standards for advanced practice physiotherapists, and, in this particular model, the role fortifies the stroke team and allows neurologists to focus on their medical expertise.
“Our approach to early supported discharge enhances patient care and shortens hospital stay,” said Rajendran. “Since the program’s launch, there has been a marked improvement in stroke care due to collaboration between internal and external stakeholders. Stroke neurologists appreciate timely functional assessments and clear rehabilitation plans. This support increases doctors’ confidence in discharging stable patients, ensuring that they are on the right path to recovery.”
MOTIVE bridges a major gap, especially in the Emergency Department, said Dr. Singh.
“As a neurologist, I could make medical decisions, but I needed the input of the interdisciplinary team to make the best plan,” he said. “Now that we have that, and it’s working well, we can avoid hospital admission in select cases.”
The MOTIVE team has received widespread support from staff across HSN.
“Other units recognize stroke care is highly specialized,” said Zeman. “They welcome our team’s input and collaborate with us to improve stroke care hospital-wide. You can’t change the system with just one service, but when you start connecting the pieces — early assessments and diagnostic imaging, prompt referrals to other programs like inpatient rehabilitation, outpatient therapy, or in-home services — it makes a significant difference.”
Christine Perras, 68, who recently underwent the specialized stroke treatment called endovascular thrombectomy (EVT) at HSN, is a beneficiary of the MOTIVE team’s rapid response to support ICU for stroke-specific assessments; consultation and input into her discharge plan.
“The whole team did an excellent job,” Perras said, smiling from her ICU bed. “I’m just so thankful to be able to drink water and have a shower again.”
Susan Bursey, Regional Director of Northeastern Ontario Stroke Network, said the team continues to take steps to optimize patient flow and further support a patient’s care journey.
“We have also added additional resources in the HSN Stroke Prevention Clinic to enable patients discharged from hospital to gain timely access to secondary stroke prevention services and medical follow-up,” said Bursey.
Early results, future sustainability
Launched in February 2025 following more than a year of planning, the MOTIVE program was funded through the Ontario Ministry of Health’s Innovative Model of Care Fund.
“While the project is supported by one-time funding for now, we aim to streamline and sustain this model over time, because we are seeing real results,” said Chantal Liddard, the Director of the Medicine Program at HSN. “The new team has seen 109 patients so far and saved roughly 70 inpatient bed days.”
Stroke is a leading cause of adult disability with nearly 1 million people in Canada currently living with stroke, and that includes more than 10,000 children. Furthermore, the number of people in Canada living with stroke has steadily increased over the past 20 years due to the aging population, and because younger people are having more strokes.
The MOTIVE project falls in line with HSN’s mission of providing exceptional people-centred care, as outlined in the new five-year strategic plan, Together For You 2030.