How Nursing Home Operators Are Responding to Severe Transportation Challenges

Skilled nursing facilities across the United States are facing mounting challenges related to transportation services, as low reimbursement rates and financial fallout from the pandemic caused some transportation companies to shut down.

The challenges are so severe that some operators are opting to eat the cost of chartering their own buses, in lieu of having residents wait for hours to get picked up for services.

Andy Aronson, President & CEO of the Health Care Association of New Jersey said that transportation has long been a critical issue, with challenges ranging from limited options for Medicaid residents, who receive transportation through the Medicaid system.


The specifics of the Medicaid transportation program can vary by state, as each state administers its Medicaid program and sets its own guidelines for transportation services. Some states may contract with transportation companies to provide these services, while others may use public transit agencies or regional transportation providers.

Aronson said transportation issues – meaning long waits for residents or just a lack of general availability for providers to plan – have not only persisted but also intensified during the pandemic due to increased costs, particularly in labor and insurance, coupled with stagnant Medicaid reimbursements.

“There is some sense, anecdotally, that it’s gotten worse since the pandemic, but it was also a problem before,” he said.


Aronson said the limited transportation options for Medicaid residents is due to state contracts with transportation providers, leading to a lack of competition and potential service struggles. He added that costs for labor and insurance have increased since the pandemic, and Medicaid reimbursements have not kept up. This has caused some private transportation providers to go out of business, further reducing options.

“I think we’ve even had some private transportation providers go out of business, so there’s even less people in the market,” he said. “And I think it becomes harder for them. Particularly in rural areas, we’re seeing limited supplies.”

Finding creative solutions

Rhonda Dempsey, SVP Chief Nursing Officer at Trilogy Health Services, said that the issues with transportation were so persistent that Trilogy made the decision to charter their own buses to transport residents.

Trilogy, which is based in Louisville, Kentucky, currently operates 130 campuses across Indiana, Michigan and Ohio, and Kentucky, and recently added facilities in Wisconsin.

“What has been occurring for the last several years, especially during COVID Is the decreased availability of access to transport,” Dempsey said. “So you may have experienced a loved one that’s at the hospital and they are discharged and they’re waiting all day for transport to pick them up to take them to their next location.”

By coordinating schedules among multiple centers, Trilogy can optimize transportation services and prioritize residents’ healthcare needs, she said.

“We started out by trialing it in areas with several centers within a certain demographic area,” she said. “This way, the transport company wouldn’t just service one center but maybe three or four in the area. They coordinate schedules. Obviously, it’s about addressing a quality issue for the residents. If a resident needs specialty consultations, we can’t wait a month for them to get there.”

Specific challenges for dialysis patients

Both Aronson and Dempsey highlighted the specific challenges faced by dialysis patients. Limited transport availability for dialysis residents not only impacts their access to care but also influences SNFs’ ability to admit these patients, particularly in areas with transportation shortages, they said.

“We saw during the pandemic, particularly, and now after that there’s much more of a focus on infection prevention and control. So obviously, facilities have much more control over what the residents are exposed to,” Aronson said. “They keep them in house as opposed to sending them to outside appointments. So there’s a lot of reasons to move the services in-house.”

Dempsey noted that Trilogy Health Services has responded by establishing internal dialysis units on campus to meet the critical needs of such patients.

“The transport availability for dialysis residents is very limited, so often, when a dialysis resident is ready to go home, they’re unable to come to our center or a skilled nursing center for rehab,” Dempsey said. “Many times, these patients aren’t accepted because transport is challenging in that area. What we’ve done in areas with many dialysis patients is open internal dialysis units on the same campus where they live.”

Dempsey said the program allows residents to leave their residence, go to the dialysis unit on the same campus, get dialyzed, and return. Currently, Trilogy has five of these units: two in Ohio, two in Kentucky, and two in Indiana.

Yet even with on-site services, she said the buses were a worthwhile investment.

“Most of our campuses have buses, but we’re specifically arranging and purchasing extra transport not just for outdoor activities, taking them to the mall, or shopping, but also to ensure our residents get to doctor’s appointments promptly,” she said. “We can pick them up at the hospital to avoid them waiting for the hospital’s transport, which could take all day. It’s definitely an area where we’re facing challenges.”