The NET Model

By Leesha Lentz

Occupational, physical, and speech therapists receive specialized training and mentoring to improve skills for working with patients with dementia.

Patients with dementia often present to rehabilitation settings with little ability to engage in therapy, as they are often unable to perform the traditional tasks the rehabilitation team requires of them. Noticing the need for a more individualized approach in working with dementia patients, Phoebe Ministries, in collaboration with various academic partners, developed and studied Neurocognitive Engagement Therapy (NET). According to Phoebe Ministries' website, NET is "an innovative model for providing rehabilitation services to individuals with cognitive impairment." The model includes evidence-based best practices in dementia care, such as person-centered care planning, in conjunction with therapy. The Alzheimer's Foundation of America provided the team a $25,000 grant to conduct their study.

After assessing the research, Phoebe Ministries and its partners noticed positive patient outcomes when therapists used NET, suggesting this therapy may be an effective practice in rehabilitation services for dementia patients.

How Does NET Work?
Kelly O'Shea Carney, PhD, CMC, executive director of the Phoebe Center for Excellence in Dementia Care and who worked on the study, says there are two aspects to the NET model. First, rehabilitation therapists are taught how to work with patients with cognitive impairments. "It's surprising, but through participation in this project we realized that many physical therapists, occupational therapists, and to a lesser degree, speech therapists, may not have formal training in working with people with cognitive impairments," Carney says. "It's not necessarily part of their professional training programs."

The second step involves arming those therapists with strategies and tools to better engage dementia patients during the therapy process, according to Carney. "It's not just understanding what dementia is and how it affects a person, but what to do differently when interacting with this population," she explains. "Through the NET program, we've developed a variety of tools therapists can use in work with individuals with cognitive impairment, and they're not necessarily tools that we've made up. We've reviewed the research and explored the field of dementia care in order to bring the best practices into the rehabilitation process. That's what makes NET so effective."

For the study, occupational, physical, and speech therapists were provided with 12 hours of training and 90 hours of mentoring to better prepare them to work with dementia patients. "The way in which we put NET together, it wasn't just sitting in a room and giving them lectures and telling them how to do these things—it was a lot of hands-on learning and weeks of mentoring," says Jennifer Howanitz, MSPT, director of therapy services at Phoebe Ministries' Allentown, Pennsylvania, location, who also worked on the study. "They had the resources to change their own behaviors as to how they interact with patients who have cognitive impairment."

Some of these changes required therapists to work with their patients in a more calming environment, often in a quiet room rather than a large gymnasium setting. Another aspect of NET encourages therapists to learn about their patients' histories and activities they may have enjoyed in the past. For example, in a YouTube video that Phoebe Ministries posted online, Howanitz spoke of a dementia patient who would not engage in traditional rehab exercises or follow the therapist's instructions. Through speaking with the patient's family members, her therapist learned that the patient had previously been a dancer. The therapist then introduced music into the therapy sessions, inviting the patient to dance, and she accepted.

Patient Outcomes
The patient mentioned above became ambulatory, once again able to bear weight, and eventually became well enough to return home with her husband. This success story reflects a key outcome of the study: greater patient engagement. "One of the challenges that therapists often face is that individuals in the middle stages of cognitive decline have a lot of trouble paying attention," Carney says. "They may not understand the instructions or may be incapable of independently following through with the instructions that the therapist gives them. As a result, they disengage and may not want to go to therapy or fully participate in therapy. With the NET model, by virtue of the best practices in dementia care, we get people more engaged in the therapy, which means now they can benefit from the process."

Carney and Howanitz, along with colleagues, reported on the study's results at the 2014 Gerontological Society of America conference in a presentation entitled "Changing Hearts and Minds: Neurocognitive Engagement (NET) Therapy and the Challenge of Engaging Rehabilitation Therapists in a New Conceptual Model Serving Individuals with Dementia." In addition to greater patient engagement, the researchers reported that patients who received NET therapy experienced greater improved function than patients who received traditional therapy.

And the patients weren't the sole beneficiaries of the therapy. Forty-six therapists from occupational, physical, and speech therapy departments were assessed before and after the study on their knowledge and comfort level in working with dementia patients. Evaluations showed that after their training sessions, therapists had increased their knowledge of cognitive impairments as well as their confidence level in working with this population.

Expanding NET
While both Carney and Howanitz say the research is promising, they caution that the NET program is still a work in progress. "We are excited about the research and the outcomes of it, but we still need to continue to do further work to be able to share it with the rest of our community," Howanitz says. "We've done some lectures at different conferences and shared the findings of the research. We hope to be able to have a more polished way of sharing that with everybody over the coming year."

In the future, Phoebe Ministries also plans to develop a location where those interested in the program can work on site to learn about NET directly to implement it in their own practices, according to Howanitz. In the meantime, Carney suggests that therapists and those interested in NET review literature in dementia and person-centered care. They should also familiarize themselves with effective techniques for patients with cognitive impairments.

Carney shares one final tip. "If I would point people to one easy thing that rehab professionals can start doing today, it would be to get to know the individual you're caring for," she says. "I think all too often in rehab settings it's all about achieving the rehab goals, but we don't take a step back to think about who this person is. We need to consider where they're from, what this person did for a living, and if they have any kids. It's all about the engagement, and the best way to engage people is to get to know who they are."

The take-home message from this study is that therapists can work effectively with this patient population, according to Carney. "I think sometimes in the health care industry, we give up on the folks who have cognitive impairments, particularly those who are in the middle stages, and we tend to think if they have dementia, there's not anything more we can do for them," she says. "This model demonstrates that this assumption is not true. We can work effectively with these populations but to be effective, we have to work differently. We can't use the same approaches to rehab a 20-year-old athlete who had a knee injury and an 85-year-old who has midstage dementia. I think that is the message: Let's not give up on these folks. Let's not assume that because they have cognitive impairment, we can't set goals for improvement; but let's be realistic about the fact that we need to approach it differently."

— Leesha Lentz is a freelance writer based in Pottstown, Pennsylvania.