require education in their targeted population group, often function under a primary generic personnel model, and have high clinical related groups and programs (e.g., psychologists, social workers, nurses and nutritionists). small intermediate care facilities, together with group homes, were supported by the non-profit sector in the us, while the large facilities over 16 have not been approved for the most part (e.g., "residual institutional populations"). as an example of the federal and state financing involved, the state of louisiana in 1988 was at $22,399,971 federal funds for intellectual and developmental disabilities with $20,788,749 allocated for small intermediate care facilities, primarily operated by the private sector. the large institutional facilities at the time in the state also received federal intermediate care facilities (icfs) funds totalling $63,462,458 with the private sector operating $18,453,062 "federal funds" for "not recommended" large icf-mrs (over 16 in size). in fy 2011, in louisiana, federal intermediate care facility financing was at $341.4 million with home- and community-based services at $413.0 million. administration administration of intermediate care facilities are the state offices of mental health or people with developmental disabilities through direct regional provision or local contracts, non-profit or profit. administration of nursing homes are the state to local department of health direct to local contracts, generally for-profit. depending on size, staff may include those responsible for individual departments (i.e., accounting, human resources, etc.). nursing home administrators are required to be licensed to run nursing facilities. assisted living facilities assisted living residences or assisted living facilities (alfs) are housing facilities primarily for elders and may also have services for people with disabilities. these facilities provide supervision or assistance with activities of daily living (adls); alfs are an eldercare alternative on the continuum of care for people, for whom independent living is not appropriate but who do not need the 24-hour medical care provided by a nursing home. keren brown wilson first developed the idea for assisted living during the 1980s as an alternative to nursing home care. assisted living is a philosophy of care and services promoting independence and dignity which was promoted nationwide as a community support in the 1990s, not a new nursing facility movement. in the original conception of assisted living, wilson sought to provide similar services to that of a nursing home, but still grant the resident more autonomy. in other words, medical personnel were on-site and available to residents, but residents were still free to dictate their schedules. for example, they could eat what they wanted, and sleep when they wanted to. wilson's idea was to emphasize maintaining a consistent, satisfying quality of life for the resident. wilson's idea was first tested as an experiment in oregon, after which the idea spread, leading to more and more assisted living facilities across the nation during the 1990s. as other corporations developed more and more assisted living communities, the concept began to increasingly mimic nursing homes as opposed to the original assisted living model proposed by wilson. thus, while assisted living facilities may now offer a menu of different services, they often remain tied to nursing facilities, policies and practices which were the original source of national concern. in addition, these facilities were funded often instead of in-home services and supports for individuals and families in local communities which has been requested nationwide for over three decades. similar to nursing homes, assisted living communities are typically home to senior citizens and individuals with dementia. these communities require certification by the state. skilled nursing facilities a skilled nursing facility (snf) is a nursing home certified to participate in, and be reimbursed by medicare. medicare is the federal program primarily for the aged (65+) who contributed to social security and medicare while they were employed. medicaid is the federal program implemented with each state to provide health care and related services to those who are below the poverty line. each state defines poverty and, therefore, medicaid eligibility. those eligible for medicaid may be low-income parents, children, including state children's health insurance programs (schips) and maternal-child wellness and food programs. seniors, and people with disabilities. however, medicaid for individuals living at home, and for facilities as providers are two separate financing mechanisms (e.g., may have facility state supplements; facility payments for personnel, administration, and services) which are not separated for public review on their use. skilled nursing facilities are less "caretaking" (e.g., laundry, personal care at bed and bathing, meal assistance, housekeeping, medications, mobility, room in units, limited activities -as defined in approval applications). they offer services such as rehabilitation (physical therapy). old style nursing homes (e.g., run by counties, and now being sold to for-profit enterprises) continue to receive federal funds. the vast majority (90%) of snfs are freestanding and a few are hospital based (defined as distinct part (d/p) of an institution ). home health care main article: home care § united states "alternatives to facility care" of the 1970s included recommendations for home health and other community services. home health typically refers to a nursing visit or aide visit to assist with daily living and are provided by certified home health care agencies. barr (2007) reported medicaid funds at $47.8 billion nationally in 2008, and medicare, a different federal program at $20 billion in 2010. in the late 2000s, the annual cap on services was finally removed, and hospital care first was no longer a stated criterion. young adults and many elders would prefer to obtain services at home. those providing services are nurse's aides, personal assistance services, home health caregivers or home caregivers, "support aides", peer companions, and social day care in senior centers. they are somewhat reimbursed in insurance policies. clients wish to retain their personal physician, and may wish to obtain therapies through private offices such as mental health counselors, chiropractors, home care agencies, medication management counselors, physical therapists, county aging workers, and rehabilitation counselors. government may also offer directly or indirectly other services such as emergency assistance lines, social work visits, meals on wheels, respite or senior companions, transportation, appointments, money management, or in some instances, adult day programs, among others. however, in some areas these services are available for a limited number of hours each week, and are therefore considered to be "underdeveloped community systems" for elders. independent living (il) services have made inroads in community services to support young adults with physical and medical needs to live in their own homes and apartments, including under the new self-directed care of medicaid and medicare. in 2012 the american association of retired persons, in its profiles on long term services and supports in the states, indicated that $5,495 per person is available for home health services, $11,142 for personal care services, $10,710 for aging waiver. the average for nursing facilities is $29,533 per person. in part, this development may be traced to the arguments for "cost-effectiveness" and "cost benefits" made to shift institutional to community care. intermediate care facilities an intermediate care facility (icf) is a health care facility for individuals who are disabled, elderly, or non-acutely ill, usually providing less intensive care than that offered at a hospital or skilled nursing facility. typically an icf is not privately paid by the individual or by the individual's family, but involves federal medicaid financing with a state and federal share, and individual contribution. an individual's private health insurance and/or a third party service like a hospice company may cover part of the cost. icfs in the community have been increasingly replaced financially by home and community-based waiver services. (in fy 2011, only 8% icfs compared to 65% hcbs waiver of $48.29 billion community spending in intellectual and developmental disabilities nationally). for comparisons between intermediate care facilities large and small in intellectual disabilities, see home and community-based services: costs, utilization and outcomes in the state of minnesota (lakin et al., 2005). the primary problem with these facilities today are their exorbitant cost (reported as average of $123,053 per person, likely institutions)compared to home and community-based medicaid waiver services ($42,896 per person) which also far exceed the cost of nursing facilities (american association of retired persons, 2012, p. 14). involuntary care as an administrative decision generally, involuntary care is involved in intermediate care facilities (icfs) where a service demand has existed, and waiting lists occur for services for decades. often these waiting lists will be for community services of other kinds including home and community-based medicaid waiver services. these kinds of services have been involved with multiple lawsuits regarding equitable distribution, and are now subject to the us supreme court's olmstead decision on the "most integrated setting". regarding "nursing homes", hospitals may require placement for discharge, and decides also if the patient can stay in the hospital. this is called hospital administration. the hospital may call the ambulance, and may not inform relatives of the location of the patient. once a patient has "been moved" (transported by ambulance) into the nursing home on the hospital's approved list, the nursing home claims all rights to decision making regarding the person' care, including relative contact. by 2008, however, nursing home emancipation with elders back to homes in communities was undertaken with an extremely high success rate when conducted with independent living personnel. home health and long-term services and supports availability at the same extent as a facility nursing home has been "recommended" by community planners, professionals and academics since the 1970s, and aging personnel nationwide have been educated to that effect. currently, a new effort to train personal care attendants and develop national standards is in place. staff intermediate care facility (icf) staffing are direct service personnel and managerial personnel responsible for professional staff (including nurses and therapists), and for in house and community programming from transportation to grocery shopping, recreational activities, personal care and mobility, communication and home activities, and so forth. almost all direct service staff are considered direct support professionals. board and care homes board and care homes (residential care homes) are special facilities designed to provide those who require assisted living services both living quarters and proper care. these facilities can either be located in a small residential home or a large facility. a large majority of board and care homes are designed to room less than 6 people. board and care homes are typically staffed by licensed professionals, including nurses, doctors and other medical professionals. these facilities are regulated. board and care homes offer residents 24 hour assistance. financials cost may vary by geographical location. medicare, medicaid, and insurance plans often pay for nursing home care; personal assets are also used. personal needs may dictate which nursing home is most cost-effective for any given person. medicare and medicaid medicare is a federal program that provides health insurance for americans 65 or older. medicare covers only 100 days of care and so it is a popular choice for rehabilitation facilities. the next potential option for many is medicaid, a program administered by every state administers and certifies most nursing homes, but each state may have different eligibility requirements related to income levels and any assets involved. medicaid is normally most available after a person has exercise every other option such as using personal funds as a form of payment may cover therapy, room and board or meal plans. the centers for medicare and medicaid services is the component of the u.s. department of health and human services (dhhs) that oversees medicare and medicaid. a large portion of medicare and medicaid funding is used each year to cover nursing home care and services for the elderly and disabled. state governments oversee the licensing of nursing homes. in addition, states have a contract with cms to monitor those nursing homes that want to be eligible to provide care to medicare and medicaid beneficiaries. congress established minimum requirements for nursing homes that want to provide services under medicare and medicaid. the requirements are broadly outlined in the social security act, which also entrusts the secretary of health and human services with the responsibility of monitoring and enforcing these requirements. cms is also charged with the responsibility of working out the details of the law and how it will be implemented, which it does by writing regulations and manuals. long-term insurance long-term care insurance is another potential option to help pay for nursing home care. long-term care insurance was designed to help with the