Time, diagnosis, and medication: The institutional circuit of billing in community mental health care

This study explored the social organization of Psychiatric Mental Health Nurse Practitioners' (PMHNPs') practice in community mental health care settings. Using institutional ethnography (IE), we examined the everyday work practices of PMHNPs to uncover the ruling relations that govern their work with patients with serious mental illness who live within conditions of poverty, violence, houselessness, and discrimination. Nine PMHNPs from outpatient community mental health clinics in a large California city participated in the study. Data collection included in-depth interviews, clinic observations, and analysis of relevant clinical and organizational texts. The analysis revealed how the mental health system's electronic health record (EHR) organizes PMHNPs' work by time, diagnosis, and medication to align their patient care with billing requirements. The Specialty Mental Health Services Medi-Cal Billing Manual and the DSM-5-TR serve as key governing texts that dictate clinical documentation standards and prioritize diagnosis and medication in the interest of revenue generation. At the same time, only some of the time spent on this work is reimbursable. The EHR organizes an institutional circuit focused on billing, which is often at odds with patients' embodied lives, experiences, and needs. PMHNPs must then mediate between this ruling relation and what they know patients need. This study contributes to the literature on the social organization of mental health care in support of advocating for policy reforms that recognize the comprehensive needs of individuals with serious mental illnesses.