The Siebens Model of Clinical Domain Management: a Fast Idea, a Slow Idea

With entrepreneurial spirit in 2005 I started pursuing, full time, an idea that started to emerge in the late 1980’s while serving on an expert panel responsible for writing - and responding to public comments - the national Clinical Practice Guideline Number 16 Post Stroke-Rehabilitation. I was tasked as lead author to draft the chapter “Screening for Rehabilitation and Choice of a Setting”. Based on my Physical Medicine and Rehabilitation Department’s practice and prior criteria in the literature, I identified 5 categories to be considered: Medical Stability, Functional Disabilities, Mental Status, Physical Activity Endurance, and Caregiver Support. There was absolutely no push back nor editing suggestions on these categories from national and international reviewers. How often among physicians and others is there such a consensus?! As a colleague shared on hearing this story, “So you knew you had to run with this.” Yes. “Ah Ha” moment #1. I began wondering how to proceed as standardization in health care, when possible, was increasingly needed for quality improvement. The five categories could be reduced logically to four, an easier number to remember anyway.

In 1992 another “Ah Ha” moment occurred making for a truly “fast” idea. While reading Peter Senge’s The Fifth Discipline about learning organizations, I learned unconscious or subconscious mental models contributed to decision-making. Oh! Health care could benefit from a more conscious, whole person universal mental model of an individual’s health-related issues. Besides medical issues, we’d know patients’ functional abilities. We’d know their advance directives. This holistic mental model would guide truly personalized care.

So, this new Model evolved with 4 domains: I Medical/Surgical Issues, II Mental Status/Emotions/Coping, III Physical Function, and IV Living Environment that together provide a whole picture to manage care. Individuals’/patients’ health-related issues are organized by these 4 domains. Flexibility leaves the details of topics and plans to the given clinician or team using the Model and the time available. Each domain has a few subdomains on dimensions for inclusion.

Since its fast “Ah Ha” birth, this idea has followed, within me, the course of the Gartner hype cycle for new technologies: enthusiasm builds to a peak of expectations followed by a trough of disillusionment followed by the upward Slope of Enlightenment as appropriate applications evolve. The Model and I are, happily, on this upward Slope given published evidence.

Now I understand the idea as a “slow” one. It’ll take time for additional spread and requires discussions among many colleagues. Some have shared the Model could reinforce current initiatives like Age-Friendly Care and the Geriatric 5 M’s. After all, we showed its value as an organizing framework in care management for individuals with Parkinson’s. Please let me know if you’re game to even consider using it! Thank you. [Note: I’ve added the first “Ah Ha” moment to this Blog as it was the other half of the “fast” idea’s origin.]