Yarmouth Integrated Stroke Team

A holistic, multi-disciplinary approach to care is making a real difference for stroke patients in southwestern Nova Scotia.

The Yarmouth Integrated Stroke Unit started as a pilot project in the early 2000s. Since then, it’s served as a hub of excellence in care, demonstrating the impact of different specialties working together.

“Stroke is one of the most common neurological disorders,” said neurologist and stroke unit co-lead Dr. Sachiko Takahashi.

A stroke happens when blood flow to a part of the brain stops, and having a stroke can affect all areas of a person’s life, including cognition, mobility, speech and quality of life. Quick intervention and a team approach to treatment are critical.

This is where two specialty units – the in-patient Yarmouth Integrated Stroke Unit and outpatient Rapid Access TIA (Transient Ischemic Attack) & Stroke Secondary Prevention Clinic – really shine, bringing together a strong team that includes physicians, a physiotherapist, occupational therapist, speech language pathologist, recreational therapist, a social worker, a pharmacist, a dietician and a nurse co-ordinator.

Integrated care

Each provider brings different expertise.

“As a physician, my main job is to limit the damage from the stroke and prevent future events,” said Dr. Brian Moses, general internist and co-lead for the stroke team. “This can be achieved by controlling their blood pressure, cholesterol, etc.”

Moses explained physiotherapy focuses mainly on lower extremity recovery after stroke,  whereas upper extremity weakness is typically managed by the occupational therapist. The occupational therapist also helps address specific life tasks, says Moses, using kitchen assessments as an example of how they help patients return to daily activities like cooking.  

Recreation therapy helps to implement people’s hobbies into their therapy; pharmacy helps ensure medications won’t interfere with the rehab process; social work helps identify what’s needed in the home; the dietician ensures the patient is meeting nutritional and hydration needs, and works with the speech-language pathologist on any issues around swallowing.

The team regularly meets to review patient progress, with everyone giving input into the care plan. The patient and family are invited to come in at the end to get an update on what the team has been doing, the challenges and progress they’re seeing, and share feedback.

“The strength of the stroke team are the people in it. Our therapists are so dedicated,” said Moses, a native Nova Scotian who joined the team as a team lead in 2008. “I can’t say enough good about them. And I know that the people who participate in the program can’t say enough good about them.”

Takahashi agreed, adding that the small team and consistent staff fosters collegiality among members.  

The benefit of this care is felt by patients primarily in the Tri-County area of Yarmouth, Digby and Shelburne, but also from the South Shore district and Lunenburg and Queens counties.

“For almost 18 years, I've been able to see people who were at death's door who have gone on to live very healthy and productive lives,” said Moses. “The best part of my job is being able to be even a small part of somebody's journey,” said Dr. Moses, who is also an MD recruitment and retention lead in the Western Zone.

Takahashi agrees that patient progress is one of the most rewarding parts of the job.  

Relatively new to the team, Takahashi joined Nova Scotia Health in September 2025, eager to return to a smaller community like the one in interior British Columbia where she grew up.  In fact, it was a surfing trip that prompted her and her husband to look into opportunities in Nova Scotia. Now, the family – which includes three young children – is enjoying the ocean, lakes and nature.

Takahashi is proud of the service the team provides and the impact they’re making in Nova Scotia’s Western Zone.

“Everyone in Canada should have access to equal care, regardless of where they live.”

Photo of (L-R) Dr. Brian Moses, internal medicine & Yarmouth Integrated Stroke Teamco-lead; J Rodriguez, physiotherapist; Stephanie Goodwin, occupational therapist; Elizabeth Kaitharam Thomas, social work; Chloe D’Eon, recreation therapist; Kelly Goudey, RN, stroke co-ordinator; Lianne Comeau, pharmacist; Kally Wells, dietitian; Dr. Sachiko Takahashi, neurologist & Yarmouth Integrated Stroke Team co-lead.

**Missing from photo: Katie Perkins, speech-language pathologist.