Few patients with nonfavorable risk (NFR) acute leukemia and myeloid dysplasia syndrome (AL/MDS) undergo allogeneic transplantation (HCT). We assessed whether this could be improved by integrating HCT/leukemia care and the use of haploidentical donors. Of 256 consecutive patients aged <75 years who received initial therapy at our center for NFR AL/MDS from 2016 to 2021, 147 (57%) underwent planned HCT (70% for patients aged <60 years). In the logistic regression analysis, age (OR 1.50 per 10-year increment; P < .001) and race (Black vs White [OR 2.05; P = .023]) were significant factors for failure to receive HCT. Reasons for no HCT included comorbidities (37%), poor KPS, lack of caregiver support, refractory malignancy (19% each), and patient refusal (17%). Lack of donor or insurance were rarely cited (3% each). In older patients (≥60 years), comorbidities (49 vs 15%; P < .001) and KPS (25% vs 10%; P = .06) were more common, and lack of caregivers was less common (13% vs 30%; P = .031). In Black vs White patients, lack of caregivers (37% vs 11%; P = .002) was more frequent. The median time from initial treatment to HCT was 118 days and was similar for Black and White patients. Landmark analysis showed that HCT within 6 months of the initial treatment produced better survival. Multivariable analysis showed that HCT resulted in a significant survival benefit (HR 0.60; P = .020). With the above approach, most of the currently treated patients aged <75 years can access planned HCT. Black patients remain at greater risk of not receiving HCT.