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Physical rehabilitation therapists are recognizing increasing numbers of older clients presenting with cognitive impairment in the post–acute setting. Therapists working with these patients often feel ill-prepared to address the special challenges of this population and often experience difficulty fully engaging the client in therapy. Decreased engagement in a therapy plan of care may lead to worse functional outcomes and increased debility. The purpose of this study was to examine the efficacy of neurocognitive engagement therapy (NET), a new model for rehabilitation, through a randomized clinical trial. Neurocognitive engagement therapy utilizes evidence-based best practices in dementia care as well as task-specific practice to increase engagement and therapeutic gains among individuals with cognitive impairment in the post–acute setting.Eighty-five subacute rehabilitation patients participated in the study, with 43 in the active group who received care based on the NET model and 42 in the control group who received traditional post–acute rehabilitation services. The groups were randomly assigned by location of the post–acute admission. The Pittsburgh Rehabilitation Participation Scale was used to measure patient engagement in physical, occupational, and speech therapy. The Modified Barthel Index was used to assess change in overall function.Results revealed that Active group participants demonstrated higher mean engagement ratings across all 3 NET therapy types (Ps ≤ .05), with the same mean number of sessions. A Group-by-Time ANOVA revealed a significant interaction effect (P = .05) for pre-/postfunctional gains on the Barthel, indicating more functional gains in the Active group. After accounting for individual differences in engagement, hierarchical multiple linear regression modeling demonstrated that engagement mediated the effects on functional improvement. That is, active patients appeared to have greater functional gains because they had higher engagement.The results suggest that NET is efficacious for cognitively impaired patients. Patients who received NET were more engaged in the process of therapy and had greater functional gains than those who were cognitively impaired and received traditional rehabilitation.