In 2010 a study by a local newspaper in Hamilton, Ontario identified major health disparities in access and outcomes within a circumscribed 10 block area of North Hamilton, including significantly shortened life expectancy. 10 years later a follow-up study showed that things had actually got worse for most of these indicators. To respond to this situation, the Hamilton Family Health Team – an integrated network of 170 family physicians and multiprofessional teams in 90 practices – developed a project to establish a primary care clinic within a community centre in one of the most deprived neighbourhoods in Hamilton, where over 20% of the population had no access to primary care. The project has been guided by two key principles a) everything we did needed to include attempts to reduce poverty and food insecurity and 2) mental health care would be a integral part of all clinical and community activities from the outset. This presentation outlines the steps taken to establish the clinic, with maximum community involvement and engagement, and the programs that have been developed. It also describes how we have been able to integrate public health data and other community indicators of economic and social wellbeing, with the findings from the introduction of a tool that all new patients complete (SPARK) that collects socio-economic data on every new enrollment and data from the clinical records to build a more comprehensive picture of community needs and assets, and to use this data to enhance individual care as well as shaping population health initiatives.