The purpose of this final project is to explore options in community based long term care that might be used in states appearing to have an institutional bias as evidenced by their Medicaid spending patterns. Several theories are explored surrounding the increased need for long term care based upon the growth of the United State's aging population. The foundation of the research is the assumption that most individuals, regardless of age, prefer to live in their own familiar surroundings if the need for long term care becomes a necessity. Subsequent ideas are discussed suggesting that spending patterns across states can help identify locations demonstrating progress in the development of models of care appearing to be successful in helping meet the goals of achieving autonomy and quality of life. One design of care known as Cash and Counseling is highlighted and suggested to be the framework for many other states' variations of flexible consumer driven care. An analysis of public long term spending across the U.S. including costs per enrollee help determine which states' care models are highlighted, as well as states that might benefit from replicating these programs. Background summaries of six programs have also been incorporated into this research project. Rates of institutionalization and data reflecting instances of care deficiencies help describe life quality and consumer and caregiver issues in skilled nursing facilities. Interviews with those engaged in community based programs are used to contrast institutional care against community based models and to support the notion that that most individuals and families find flexible consumer oriented models of care a preference over traditional methods of maintaining their health and quality of life.