Bringing the caregivers to the patient: transportation as essential infrastructure in home health care for older adults

As the population ages, millions of older adults depend on the essential care provided by home health aides (HHAs). HHAs represent a frontline workforce that supports aging-in-place in one’s own home—the lowest-cost and most preferred care setting for older adults (Geng et al., 2024; 2025; Landers et al., 2016). HHAs help maintain health, dignity, and independence among older adults, especially those living with cognitive impairment or dementia, while easing strain on familial caregivers. Despite their indispensable role, however, HHAs face challenges related to social determinants of health (SDOH) that adversely affect their own wellness and ability to deliver care. Among the most pressing—and often overlooked—is transportation (Louis et al., 2024; Stone, 2017). Our view is that transportation is an essential component of home health care infrastructure. Yet, the current standard in home care is that HHAs are responsible for arranging and paying for their own travel to and from patients’ homes (Louis et al., 2024; PHI, 2023; Stone, 2017). In fact, for many home care agencies having access to a car is a requirement for employment. Agencies typically do not reimburse costs for mileage, gas, parking, or public transit fares. Thus, HHAs bear substantial out-of-pocket expenses that erode already lower-end wages (Markkanen et al., 2007), while those without access to a car may face long, unpredictable commutes on public transit. The time, cost, and stress associated with travel compound the challenges of a workforce already vulnerable to financial insecurity and limited career mobility (Muench et al., 2021)—ultimately contributing to high turnover (Markkanen et al., 2007; PHI, 2023). Finally, lack of affordable, accessible, and reliable transportation for HHAs is not only a workforce issue but also a health care access and quality issue. Missed or delayed home care visits because of transportation problems have the potential to cascade into health declines among aging adults, such as emergency department visits, hospitalizations, or premature institutionalization. Thus, the transportation challenges that affect HHAs have direct implications for the health, independence, and quality of life of the people they serve. Transportation is an essential component of home health care infrastructure. Lack of affordable, accessible, and reliable transportation for HHAs is not only a workforce issue but also a health care access and quality issue. Missed or delayed home care visits because of transportation problems have the potential to cascade into health declines among aging adults, such as emergency department visits, hospitalizations, or premature institutionalization.