From 180 mental health crises a year to 776: Why did this coroner’s workload grow so much?

For four years, the Tangipahoa Parish The coroner quadrupled the number of consultations he conducted with people believed to be suffering from a mental health or addiction crisis, appointments in which he would decide whether patients should be held in treatment centers against their will.

Coroner Dr. Rick Foster did 180 of those inquiries, called Coroner’s Emergency Certificates, in 2018. He did 230 in 2019 and 363 in 2020, parish payroll records show. In 2021, the previous year’s number more than doubled: Foster completed 776 screens that year.

In October, six weeks after Hurricane Ida, Foster visited four mental health patients in a single afternoon. Records show that it was one of three times in a two-week period when he saw that many patients in one day.

Foster and others in his field attribute the growing demand for these consultations, a duty given to Louisiana medical examiners under an obscure state law, to the rise in mental health crises caused by the COVID-19 pandemic. Combined with the opening of several new psychiatric care facilities, he says his office is stretched thin.

Foster said he used to do more exams in emergency rooms for patients who would later be transferred to facilities outside the parish.

“Now I can hardly go to the ER because I am so busy seeing the patients that are in the new facility,” he wrote in an email.

The screenings Foster was doing became so frequent that they took local Tangipahoa officials by surprise.

The “CECs” cost taxpayers, because the parish reimburses Foster for each appointment. Under his current agreement with the parish, Foster personally earns $100 for each CEC appointment he makes. In 2021, consultations earned him $77,600 on top of his salary of $40,574.

That cost has grown so fast that parish leaders decided to split the coroner’s budget from the rest of parish government.

How CECs Work, How the Medical Examiner Gets Paid

The Coroner’s Emergency Certificate process exists because of a little-known state statute That gives medical examiners, locally elected officials whose main job is to determine how people died, a duty to offer second opinions on whether seriously mentally ill patients require hospitalization for more than a couple of days.

It’s a process unique to Louisiana that often leaves people stumped, said Richard Kramer, director of the Florida Parishes Human Services Authority and a former psychiatric hospital executive. In other states, other health care workers often manage those kinds of screens.

“It seems a little strange when you start to think about it, because medical examiners are usually thought of for another reason,” Kramer said. “If we start having a conversation in some kind of setting with people from other states, and I mention the coroner, all of a sudden people look at me like I was wrong.”

Medical examiners perform the screens at the request of hospital doctors.

If a doctor wants to keep a psychiatric care patient in a hospital facility longer than 72 hours, he or she must have a medical examiner sign a Medical Examiner’s Emergency Certificate, or CEC. To sign the certificate, a medical examiner must determine that the patients are a danger to themselves or others or that they are severely disabled to the point that they must remain hospitalized for up to 15 more days.

The settlement makes sense in part because, except in very rare circumstances, coroners are medical doctors, said William “Chuck” Credo, an attorney and mental health law expert who has represented coroners across the state. That gives officials a degree of expertise in offering second opinions on patients’ mental health.

There is no centralized database of CEC trends in the state. But most of the time coroners are called in, they approve the request, Credo said, because most of those patients are still in crisis.

“That’s not to say that for most people going through a mental health crisis, the crisis is not resolved,” Credo said.

State law gives local governments discretion to decide how medical examiners are paid to do CEC, saying “the examining medical examiner shall be entitled to the rate authorized by law in his or her parish.” For some coroners, CEC appointments for parish residents are covered by their parish salary.

Requests are increasing everywhere

Differences in hospital services and population size, mean trends in the number of ECCs performed by medical examiners, are difficult to compare in Louisiana. A booming suburban area like Jefferson Parish has far more health care facilities, residents and hospital beds per capita than rural upstate parishes, for example, leading to more requests for medical examiners to evaluate patients.

Still, coroners and mental health professionals across South Louisiana echoed Foster’s message that the pandemic-related mental health and substance abuse crises have increased the demand for screens.

In Jefferson Parish, the coroner’s office conducted approximately 4,000 CECs each year in 2018, 2019 and 2020, according to data provided by the office. The figure rose in 2021 to 5,216. Similarly, East Baton Rouge City Parish Coroner Beau Clark made between 7,500 and 7,900 CEL every year from 2018 to 2020; then in 2021 his office made 8,433 of the displays.

And in Orleans Parish, the number soared to 4,482 in 2021, from 2,457 in 2018, 2,792 in 2019 and 2,586 in 2020, according to data provided by a parish spokesperson.

An outlier in the region was the St. Tammany Parish coroner’s office, which recorded 2,659 CECs. until the third quarter of 2021 — on the way to not reaching the parish figure 2020 for about 100 citations.

Even the Livingston Parish Coroner, which does a fraction of the CECs done in larger parishes because the area has few hospitals, saw a two-fold increase in the last year: The office did 170 CECs in 2021 after doing 84 the previous year, the office secretary said.

Coroners described the demand for late-stage mental health resources as a different kind of hospital overload than the one that is at the center of the pandemic.

“The mental health issues that have accompanied COVID are enormous,” said Dr. Gerry Cvitanovich, Jefferson Parish coroner and president of the Louisiana Coroners Association. “It’s crazy, from a mental health perspective, how taxed the system is right now.”

The fourfold increase in Tangipahoa in the CECs over as many years is more pronounced than in other parishes. But the severity of the pandemic’s mental health effects doesn’t necessarily make such an increase unusual, Credo said.

The pandemic has pushed the demand for behavioral health services “to crisis levels,” said Robin Embry, a spokesperson for the Oceans Behavioral Health network.

The network opened a psychiatric care hospital in the town of Kentwood, in Tangipahoa Parish, last year, Embry said, in addition to another facility in Hammond the year before. Universal Behavioral Health Hospital in Hammond also requests CEC, Foster said, meaning there are at least three dedicated mental health facilities in the parish requesting the screenings, in addition to the general service hospitals.

‘You should be able to run your office’

Along with other rising costs, the growing number of commitment orders prompted parish officials in Tangipahoa to begin asking if there is a way to make coroner’s costs more predictable.

To date, Foster’s office workers have been classified as employees of the Tangipahoa Parish government. Foster and the council are negotiating a new deal that would give Foster’s office its own annual budget of $875,000, with which he would manage his own payroll and expenses, similar to the district attorney’s office or court clerk.

“A lot of what we’ve been doing with the coroner is recognizing that he’s a duly elected parish official and should be able to run his office,” said Tangipahoa Parish President Robby Miller.

Currently, Foster said, the coroner’s office is the only government office in the entire parish that falls entirely under the authority of the parish council. The agreement, which he said was mutual and will go into effect later this spring, “will make us like any other Parish Government Office,” Foster said.

Parish leaders said the deal will allay concerns about the unpredictability of the office’s finances.

Foster said the trends they are concerned about are the result of his office being overwhelmed at an unprecedented time. The pandemic created a mountain of additional work for the Coroner’s Office, between an increase in autopsies and increased demand for mental health care.

His small rural office does not employ specialists like the psychiatrists who work for some larger coroner’s offices and may share the burden of doing CEC. It’s been hard to keep up, Foster said.

“The volume has gone up tremendously and I’m basically doing it all, over 99%, by myself,” Foster said.