Integrating the best available evidence into program standards and practice is essential if system-wide improvements in the delivery of community-based mental health services are to be achieved. In the case of Assertive Community Treatment (ACT) programs, a second iteration of program standards has recently been developed in Ontario, Canada to facilitate the evidence-based delivery of these programs which are designed to provide community-based services to individuals with serious, persistent mental illness. Features of the ACT approach include: delivery of comprehensive services in individuals' immediate communities and homes; individualized treatment plans; access to services 24 hours a day, seven days a week; and, services provided by a collaborative team of multi-disciplinary experts. ACT program standards are developed to help ensure that treatment programs are implemented in a manner consistent with evidence-based practice. These standards typically include criteria for such functions as: organizational structure and communications; required staffing; procedures for intake, admission and discharge; maintenence of client records; clinical services; and community participation.
At the core of the ACT model's "community-based" philosophy is not only the delivery of services in the community but also the participation of members of the community in the governance of the program and the delivery of services. The use of community members in providing oversight to program operations (both as members of the Board of Directors and in an advisory capacity) has been a long-standing practice for organizations delivering community-based services, however, the use of "consumer providers" in the delivery of services, or "peer support specialists" as they are referred to in ACT programs, is a relatively recent phenomenon. Community participation activities have been identified as important elements in facilitating mental health recovery [1–4] which is at the core of their inclusion in formal program standards in other jurisdictions [5, 6]. However, the importance of community participation standards does not appear to be reflected in either the academic research or programmatic evaluations of the ACT model since this area has been understudied and there is inadequate guidance for program administrators regarding how to successfully implement these standards. Thus, there is a need to identify and better understand how to overcome, barriers to the implementation of these community participation program standards to achieve system-wide improvements.
The purpose of this article is to report on the extent to which ACT programs in Ontario, Canada have implemented program standards relating to community participation and to examine specific barriers which may be inhibiting full compliance with these standards. We specifically examine the use of community advisory bodies (CAB) and the requirement that a peer support specialist be a member of each ACT team. For both of these standards we identify, from the Program Coordinator's perspective, the perceived levels of compliance with these standards, and how essential they believe these standards are to the effective functioning of their ACT program. This article begins with some background on the ACT model, its formal adoption in Ontario, and the two program standards that most directly relate to community participation - Community Advisory Bodies and Peer Support Specialists. The article then outlines the study's methodology and results, followed by an analysis and discussion of the major barrriers to implementation of the two community participation standards.
Mental Health Reform
Mental health reform has been a high priority on the public policy agenda of most Ontario governments since the 1980s as is evident by the array of government reports produced [7–9]. Much like other health care reform initiatives, mental health reform has been driven by the need to control costs and the desire to repair deficiencies in the system. These deficiencies include fragmented availability of mental health services across the province, lack of accountability to clients and the public, and an inadequate ability to respond to local needs due to the government's centralized decision-making process .
Over the years, a major focus of mental health reform initiatives worldwide has been, and continues to be, a shift from institutional to community-based services. To facilitate this shift in Ontario, in the late 1990s the Ontario government began to divest itself of provincially owned psychiatric hospitals. As an alternative, the government directed more funds towards community-based care. By 1998 the Ontario government formally endorsed the use of ACT programs as a mechanism to reduce acute hospitalizations and support the provision of services to individuals with serious mental illness in the community .
ACT programs in Ontario are intended not only to provide community-based care but are to be sponsored by an organization within the immediate community. A community organization, usually a hospital or a not-for-profit health care organization, identifies the need for an ACT program within its community and applies to the Ministry of Health and Long Term Care for funding approval to operate an ACT program. If Ministry approval is granted, funds for the operation of the ACT program are administered through the sponsoring agency which is responsible for the operation of the program in accordance with program standards.
The approach on which the ACT program model is based originated in the United States in the early 1970s . This community-based approach is predicated on the belief that serious and persistent mental illness requires intensive psychiatric, medical, and social support interventions and that these services are best provided in the community where the individual lives and must function, versus the traditional "institutionalized" approach which has been shown to be less effective [12, 13].
Several measurment scales have been developed as a means to assess fidelity to ACT program standards [14–16]. The ACT model of care has long been shown to result in improved outcomes for individuals with serious mental illness  and, increased cost effectiveness versus other approaches to the delivery of mental health services [17, 18]. Positive outcomes include: decreased family burden; reduced symptoms and program dropout rates; improved social functioning; reduced hospitalization rates; and, enhanced family satisfaction [17–23]. However, in order for these positive outcomes to be realized it is necessary for consistency in implementation of program standards. This evidence-based practice, linking positive outcomes to compliance with ACT program standards, encouraged the Ministry of Health and Long Term Care in Ontario to conduct a review of the 1998 ACT program standards. In 2004 the government issued a 39-page revised version of the Ontario Program Standards for ACT Teams , providing minimum standards for program operation and descriptions of the rationale for the requirements. The standards define:
(1) for whom a program is intended; (2) the required services; (3) the type of staff/numbers needed to competently provide the services; and, 4) the intended benefits/outcomes for the clients receiving the services. Program standards are used to establish costs and are used for program monitoring and compliance purposes.
Descriptions are provided for standards that include: intake, admission and discharge; service intensity and capacity; staff requirements; program organization and communication; client-centered assessment and individualized treatment and service planning; required services; maintenance of client records, procedures to resolve complaint resolutions; performance improvement and program evaluation; community advisory bodies; and accountability .
Two of the standards specfically provide for the inclusion of individuals from the immediate community in the functioning of the local ACT program. These are the standards for Community Advisory Bodies and for Peer Support Specialists.
Community Advisory Bodies
Under the 2004 program standards, each ACT program is to establish a Community Advisory Body (CAB) which consists of a group of volunteers from the local community, including consumers of mental health services, who provide advice to each ACT program. The specific standard notes that:
The ACT team shall relate to a community advisory body which supports and guides ACT team implementation and operation ... The community advisory body is accountable and reports directly to the Board of Directors of the sponsoring agency. Members are chosen for their expertise in mental health or addiction services, their links with other relevant community services, their ability to represent the interests of clients and their families and the community, and other expertise required to direct a mental health service. Members should include mental health consumers and commuity stakeholders that interact with persons with serious mental illness ... [and] shall also reflect the diversity of the local population.
While CABs do not have any formal authority over the operation of their ACT programs, previous research found evidence that the direct participation of qualified individuals and organizations from the community in the design and delivery of mental health services has a valuable impact on the success of the programs. For example, research findings suggest that the community's participation in mental health initiatives provides a valuable and different perspective from that of traditional health service providers  and, is an important factor in predicting healthier communities . Thus, the program standard for CABs specifically requires that "... the community advisory body shall have written terms of reference incorporating the requirements outlined in ..." the revised ACT program standards .
Peer Support Specialists
The 2004 program standards also provide detailed requirments for staffing programs. Each ACT team is to be composed of specified minimum staffing levels, including a Program Coordinator, registered nurses, an occupational therapist, a substance abuse specialist, a vocational specialist, a peer specialist, other clinical staff (e.g., a psychiatrist), and a program/administrative assistant. The requirement for peer specialists, a unique addition to the traditional team of health professionals, pre-dates the revised 2004 standards for ACT teams in Ontario, although prior research indicates that there was considerable inconsistency with how the role was defined and its degree of integration with other ACT team members .
ACT Teams are expected to promote client-centered practices by the deployment of a peer specialist .... Peer support services serve to validate clients' experiences and to guide and encourage clients to take responsibility for and actively participate in their own recovery. In addition, services help clients identify, understand, and combat stigma and discrimination against mental illness and develop strategies to reduce self-imposed stigma.
The Peer Support Specialist is a representative from the community who has had personal experience in treatment program(s) for serious mental illness, and who can provide counselling and support to current clients. Services provided by the Peer Support Specialist include: serving as a role model; helping clients to develop coping mechanisms; sharing experiences; educating the ACT team members and staff about the client perspective; serving as an advocate for the development of initiatives within the community that will facilitate client empowerment; and, making clients aware of self-help programs and organizations that can be helpful in their recovery .
The program standards require the use of Peer Support Specialists because they are believed to enhance the overall functioning of ACT programs. Reported findings from several researchers indicate that Peer Support Specialists contribute to improved client/consumer outcomes when incorporated into the delivery of mental health services [28–31]. Despite this, the integration of non-professional peer service providers (or Peer Support Specialists) into the ACT service team is not well understood. This may be due, in part, to differences in role definition across programs and a paucity of rigorous empirical evaluation . Mowbray et al.  found significant role confusion in some programs, where the peer support specialist may provide functions that serve as both friend and clinician; while Lyons et al.  identified challenges in implementation where Peer Support Specialists were less likely to be dispatched in an emergency than were other ACT team members. In their 2003 survey of ACT programs in Ontario, White et al.  found that Peer Support Specialists were not fully integrated into existing ACT teams; and, 22% of the respondents indicated that they were not planning to implement such a position. Thus, a number of challenges exist regarding the use and implementation of consumers as service providers in mental health services.
This study adds to the international literature on the integration of local community members in the design and delivery of mental health services. These findings will be instructive to an international audience in that they provide both quantitative and qualitative data generating new insights into barriers and facilitators to the compliance of program standards focused on enhancing the community's role in the provision of mental health services. Additionally, this study provides concrete information that may be used by decision-makers within Ontario, including politicians, sponsoring agencies, and program managers, to take decisive action to make improvements to the quality of local mental health programs and the services they deliver.