The Siebens Domain Management Model and Dementia

A senior research leader suggested a blog on the Siebens Domain Management Model (SDMM) applied to individuals with dementia and their care partners. Here’s my followed-up.

The Model is an organizing framework for individuals’ health-related issues. Originating from my own patient care, the Model’s four domains guided me and our teams’ care. Cognitive problems were frequent concerns. We’d do assessments to identify issues for individuals and care partners (a dyad), problem solve collaboratively, and, together, prioritize a plan’s next steps. Here’s a snapshot of how the Model would apply:

I Medical/Surgical Issues – any immediate problems requiring stabilization (blood glucose, etc.). In dementia, individuals’ care partners risked lack of sleep, medication non-adherence, and uncontrolled chronic conditions. The longer time and higher intensity of burdensome care, the more likely care partners would develop medical/surgical issues. (3)

II Mental Status/Emotions/Coping – type of cognitive issues; depression or anxiety; coping strategies and behaviors (agitation, wandering, etc.); spirituality; preferences (wishes for future care, What Matters (4)). For an individual needing guidance and/or physical help from a care partner, how is that experience going? For a care partner, are there rewards in the caregiving? Are there strains? (5) Are they resenting loss of personal free time or experiencing guilt from difficulties keeping up the caregiving?

III Physical Function – Because individuals want to remain at home as they age, the ability to function day-to-day is critical. Are there issues in basic, intermediate, or advanced activities of daily living? For care partners, how is their caregiving, an advanced activity of daily living, working out? What is physically entailed? Is additional help needed?

IV Living Environment – A. Physical Environment – are there stressors (noise, lack of privacy, stairs, no housing, etc.); B. Social Environment – who in the community might visit or do activities with them to preclude social isolation? and C. Community and Financial Resources – are there discrete issues that a specific community resource addresses? (5)

Clinical discussions wouldn’t necessarily follow the above order yet would touch on each domain, even briefly if time was short. Plain English words would be used in discussions. (6)

Because the SDMM facilitates identifying day-to-day issues, it can help engage individuals and care partners in their own care. As a practical communication and care coordination tool, it can be used verbally, as in team and family conferences, or in written format in documentation and individuals’ self-care plans. This process may help care partners acknowledge health issues that compromise their caring and the need for support to maintain their own well-being.

More work is necessary on ways to focus on the dyad of an individual with dementia and their care partner/caregiver. Some health systems now pay attention to care partners’ needs. (7) The SDMM can organize a teams’ comprehensive yet efficient proactive assessment of both dyad members and include discussion about the ongoing caregiving. Assessments can be followed by providing information, collaborative problem solving, and prioritizing next steps. Among the goals to be considered is maintaining the dyad’s health as best as possible.

1 The Siebens Domain Management Model (SDMM) is also called the Domain Model or Siebens Model of Clinical Domain Management. For some applications, see https://www.siebenspcc.com/ and userfriendlytools.healthcare.

2 While definitions may vary, here the care partner term implies the individual requiring help (supervision, physical help, or both) has the ability to participate in coping as his or her health circumstances change. The caregiver term reflects greater dependency in the individual such that a caregiver provides total supervision or significant physical help.  

3 Basic pathological processes resulting from stressors are part of an inflammatory cascade contributing to poor health. See Marya R, Patel R Inflamed: Deep Medicine and the Anatomy of Justice, 2021. Allen Lane, London, pp. 1-484.

4 The 4 M Framework includes What Matters, Medication, Mentation, and Mobility and are part of the Age Friendly Health System initiative https://www.ihi.org/initiatives/age-friendly-health-systems. In the SDMM, “patient preferences” encompasses What Matters.

5 Connor KI, et al. Determining care management activities associated with mastery and relationship strain for dementia caregivers. JAGS 2008; 56:891-7. Note: Home visit evaluations by care managers improved caregiver mastery.

6 Siebens H. Proposing a practical clinical model. Top Stroke Rehabil 2011;18:60-65. The framework helps overcome boundaries between the physicians and other clinicians and the day-to-day life world of patients and their families. It supplies a simple framework for capturing relevant issues and information for the purposes of communication, clinical planning, and coordination.

7 The Centers for Medicare and Medicaid (CMS) is starting the Guiding an Improved  Dementia Experience (GUIDE) Model, a voluntary 8-year program in fee-for-service Medicare. This Model envisions care coordination among multiple providers and services and includes payment to caregivers of individuals with dementia.