Q. I have had the same primary caregiver for over 15 years, but the rising cost of attendant care jeopardizes my ability to retain her.

I am a C4 quadriplegic who lives independently and works full time, but I am dependent on Sue for all activities of daily living, including getting in and out of bed. Because of my salary, benefits and other savings, I am not eligible for Medicaid, and I pay out-of-pocket for my attendant care. After 38 years of being paralyzed, I need attendant coverage for additional hours. Along with needing to go to bed earlier because I am tired, I require more care because I recently got a colostomy that must be changed during the day.

I pay Sue $21 an hour, and she works eight hours, six days a week. She gets me up and does my morning care and then comes back in the evening to put me to bed. I do not have any coverage between 11 a.m. and 5 p.m. I have a second person who comes on the days Sue cannot cover. I do not have any family living nearby, and even if I did, I don’t want to rely on family for my care.

I know I need to talk to Sue about the extra care that I need and that I cannot afford to pay her the same rate for additional hours given my current budget. The prospect of the inevitable conversation is causing me stress, so I keep putting it off. It has also been so long since I hired a primary caregiver that I’m not prepared to start a search. I worry about being left high and dry.

What if she says no to working additional hours for less pay? What other options do I have to possibly retain her? If I do need to hire someone new, how can I find someone who is so reliable and knows my needs so well?

A. This is a difficult situation, but not an uncommon one. Before you start analyzing your solution, it is worth taking a few minutes to make sure you are not eligible for any financial assistance from the state. I know you said you aren’t, but state legislation and return-to-work programs may have changed since you last investigated.

Assuming you still aren’t eligible, the first thing you should do is an analysis of your budget and care needs to understand your options. For instance, can you retain Sue for her current schedule under the existing pay and extend the hours of your other provider to cover the added hours at a lower rate?

It is also worth talking with Sue to understand her needs and thoughts. Be honest about your constraints. Sue may be willing to do the extra hours for less money. The two of you can possibly figure out a schedule where she still does your main care each day, and you find an additional person for other hours at lesser pay.

Depending on your level of trust with Sue, revealing some of your financial specifics could help. Long-term relationships between caregivers and clients are usually unique and complicated. If you two have a deep understanding and respect for each other, your candor could lead to an unexpected solution. Even if no solution is attainable, having an open discussion could help you maintain the relationship and keep other options open.

Whatever you decide to discuss, it is wise to have this conversation months before making the changes. That gives both of you time to think about the options. Sue may be unwilling to change her hours or work extra hours at a lesser rate. Therefore, even before initiating this conversation, you should take steps to prepare yourself for a potential change. You may soon need to overhaul your care schedule completely.

Think about other alternatives. Is there a college nearby with a nursing or physical therapy program where you could recruit a student to work for you at a lesser cost? It may also be helpful to talk to others in a similar situation to see if they have come up with innovative ways to sustain caregiver relationships that are not as costly. For example, if you have the space, many individuals have “live in” help, and the cost of the care is offset by rent and other expenses that the employee would typically incur.

These are all difficult and stressful issues, but your independence and health are paramount. Taking the time to ensure you have the coverage you need is imperative. Losing Sue would be a big blow, but you have to persevere.