There is increasing evidence that the context of health care delivery has direct effects on access, quality, and outcomes from care. (For an analysis of HMO penetration and poverty on access to specialty mental health care, see Grensenz, Stockdale, and Wells, 2000; for an exploration of the role of facility ownership on the transfer of patients, see Schlesinger et al., 1997; for an examination of the impact of facility ownership on timing of discharge, see Pottick et al., 1999). Drastic reductions in Medicaid and state budgets threaten our current capacity to meet the mental health needs of youth. Understanding the current relationship between organizational characteristics and service utilization is crucial to monitor the potential impact of changing fiscal arrangements.

Our specific aims for this symposium are to (1) assess the impact of organizational characteristics (e.g., organizational ownership, size, and staffing) on the use of medication in mental health services, (2) explore the way these same organizational factors are associated with racial and ethnic differences in selection into inpatient or outpatient services, and (3) investigate the influence of community resources and aftercare on psychiatric re-hospitalization patterns, all controlling on individual level characteristics, including clinical need.

The proposed set of studies looks within mental health facilities to determine characteristics of their internal operations, and relates these characteristics to medication use, racial and ethnic disparities in treatment selection, and re-hospitalization practices. The studies ask: To what extent do organizational and health care system factors determine medication practices, treatment selection processes, and psychiatric readmission patterns? In other words, are profit motives, size, staffing patterns, and community resource availability more important determinants of medication, treatment selection, and re-hospitalization than youths' demographic and illness profiles or insurance coverage?

Each of the studies in this symposium merges individual client-level data with organizational and health care system data to provide the unique opportunity to understand the role of organizations and the network of mental health care delivery systems in utilization patterns for youth.

This symposium contributes to the development of clinically and cost-effective services, by providing information about the effects of contextual, macro-level factors on policies and delivery of care for youths. We conclude with a discussion of methodological approaches in examining contextual variables, highlighting new directions and opportunities for future research.